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Budget Debates in US, UK Could Augur Poorly for Global Health Funding

25th Jul 2017

 

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By David J. Olson

Global health financing has not been in such jeopardy since the large investments in it started in 1991 – the year in which global health funding started an upward trajectory that moved higher in all but three years.

In particular, the rise of Donald Trump of the United States and Theresa May of the United Kingdom the leaders of the two largest donor nations have raised concerns about the prospects for development assistance broadly, and global health specifically.

In 2016, development assistance for health (DAH) reached $37.6 billion, eking out a miniscule 0.1% increase from 2015 that followed a pattern of little growth since 2010 (DAH grew 11.4% annually from 2000 to 2010 but only 1.8% since 2010), according to “Financing Global Health 2016,” published by the Institute for Health Metrics and Evaluation in April. DAH peaked at $38 billion in 2013, dropped to $36 billion in 2014 and has recovered slightly in the two subsequent years. This infographic provides a snapshot.

 

The U.S. and the U.K. have been the two top contributors to DAH but both countries have political environments that have called into question their future commitments to foreign aid and global health.

 

Trump’s 2018 budget request to Congress contains unprecedented cuts (more than $2 billion) to global health. If those cuts are enacted, writes the Kaiser Family Foundation, they will bring funding below 2008 levels. Family planning support would be eliminated. Kaiser predicts the cuts could result in the following scenarios starting in 2018:

 

  • Additional new HIV infections between 49,100 to 198,700;
  • Women and couples receiving contraceptives would decline from 6.5 million to almost 25 million; and
  • Additional abortions between 819,000 and more than 3 million.

 

More than half of the $2 billion in cuts to global health would come from international HIV/AIDS programs. In a new paper, the Center for Strategic and International Studies says the cuts would jeopardize U.S. leadership on HIV/AIDS and “raise the possibility that the pandemic will reignite, threatening U.S. and global health security.”

 

However, in the U.S. political system, Congress has the last word on the budget, and even Republican senators say these cuts will not stand. But however the final budget turns out, it could still perpetuate the recent stagnation in global health financing.

 

A series of hearings earlier this month featuring Secretary of State Rex Tillerson and U.S. Agency for International Development Administrator-designate Mark Green revealed how the Trump Administration is of two minds about foreign aid.

 

Tillerson testified at four hearings on the proposed budget cuts. Republicans and Democrats alike lambasted the proposed cuts. Sen. Lindsay Graham, the Republican chairman of the Senate subcommittee that oversees foreign aid, said these cuts would put lives at risk. Tillerson defended the cuts, saying “Our budget will never determine our ability to be effective. Our people will.”

 

Good news came with the nomination of former Ambassador and Congressman Mark Green to lead USAID. Green was well received by both political parties in his testimony before the Senate Foreign Relations Committee on June 15, and he talked with pride about the work of USAID (we also learned that his parents were born South African and British).

 

For global health advocates, one of the most worrisome aspects of Trump Administration policy has been the reinstatement and expansion of the Mexico City Policy. This policy requires foreign non-governmental organizations to certify that they will not “perform or actively promote abortion as a method of family planning” using funds from any source as a condition for receiving U.S. family planning assistance.

 

Green tried to calm concerns about the policy. “The State Department is undertaking an intensive six-month review to study the impacts of the expanded policy and whether it leads to interruption of services on the ground,” said Green in his testimony. “USAID will be part of that and we will play it straight. You can count on us to be honest brokers in that process.”

 

In the U.K., meanwhile, a different scenario has been playing out. In 2013, the UK became the fifth country to reach the UN goal of dedicating 0.7% of its gross national income to foreign aid, driven in large part by former Prime Minister David Cameron. But after the Brexit upset in 2016, Theresa May became prime minister and appointed conservative Member of Parliament Priti Patel as her international development secretary.

 

At the time, Patel roundly criticized British aid as being a waste of money and promised a major overhaul of the aid budget, according to the Daily Mail.

 

“My approach will be built on some core conservative principles that the way to end poverty is wealth creation, not aid dependency; that wealth is ultimately created by people, not by the state; that poor countries need more investment and trade, not less,” she was quoted in The Guardian. “And we need to empower the poorest to work and trade their way out of poverty, not treat them as passive recipients of our support.”

 

In March 2017, a cross-party parliamentary committee on international development concluded that “ODA [official development assistance] spending is in the national interest and is a strong investment contributing to create a more prosperous world, which pays far-reaching dividends including to UK taxpayers at home.” The committee did not find evidence of wasteful spending. In fact, they found the spending to be effective.

 

Recently, Patel has struck a more positive tone about ODA. She announced a new aid package for east Africa, boasted about the scale of UK development assistance and, when asked about the future of UK aid, said: “It’s never been so needed. We face more global challenges in 2017 than every before.”

 

We don’t know if global health funding will go up or down but one thing is clear: Green and Patel are both interested in finding approaches to foreign aid that go beyond treating people as passive recipients of cash and that spark more economic investment and trade. It will be interesting to see what that means for global health.

 

 

Health Workers, Facilities Under Attack in 23 Nations; UN Accused of Inaction

23rd May 2017

This hospital was damaged by clashes during a 79-day curfew from late 2015 to early 2016 in the city of Cizre in southeastern Turkey. Photo: Physicians for Human Rights

This hospital was damaged by clashes during a 79-day curfew from late 2015 to early 2016 in the city of Cizre in southeastern Turkey. Photo: Physicians for Human Rights

By David J. Olson

In 2012, two Pakistani health workers were out vaccinating children against polio when they were both shot by extremists. One of them died. The other, shot in the leg, had 11 metal rods inserted into his leg and was hospitalized for three months.

In November, I met this remarkable man named Latif (his surname is withheld to protect his security). He is now fully recovered and back to work on the polio vaccination campaign. He told me he never considered giving up. Pakistan reported only two cases of wild poliovirus in 2017 as of May 17 and Latif is determined to see the polio campaign through to the end.

The attack on Latif is only one example of a tragic phenomenon that is not getting better – violence against heath workers and health facilities. In 2016, the extent and intensity of such violence “remained alarmingly high,” according to a new report released by the Safeguarding Health in Conflict Coalition.” The report also found that accountability for committing these attacks remains inadequate or non-existent.

The violence isn’t always perpetrated by terrorists. Sometimes it is committed by the police or the country’s military institutions that should be ensuring tranquility.

Most of us have heard of hospitals and clinics getting blown up or polio vaccinators getting shot but the report indicates that attacks on health care take many forms. It names eight different forms of violence:

      •  Bombing and shelling of health facilities (reported in 10 countries in 2016)
      •  Looting of health facilities (11)
      •  Killing of health workers, emergency medical personnel and patients (11)
      •  Intimidation, assault and arrest of health workers and patients (20)
      •  Abduction of health workers (11)
      •  Obstruction of access to care including blockage of and attacks on ambulances (10)
      •  Takeover and occupation of health facilities by police, military or other armed actors (7)
      •  Attacks on and blockage of humanitarian actors, supplies and transports (15)

 

The report documents attacks on health care in 23 countries in 2016. Most of the countries are in Africa and the Middle East but there are a few exceptions (Armenia, India, Myanmar and Ukraine). The report was released on May 3, the first anniversary of the UN Security Council’s adoption of Resolution 2286 that set out a roadmap to the protection of health workers in conflict.

The Safeguarding Health in Conflict Coalition says the UN Security Council has failed to follow through on its own recommendations for preventing attacks and providing accountability for those who commit them. These recommendations include regular reporting to the UN on actions taken to prevent attacks, to investigate attacks, and to hold perpetrators accountable. The U.N. Press Office did not respond to my request for a comment.

“Our findings cry out for a level of commitment and follow-through by the international community and individual governments that has been absent since the passage of Security Council Resolution 2286 a year ago,” said Leonard S. Rubenstein, chair of the coalition and director of the Program on Human Rights, Health and Conflict at Johns Hopkins University Bloomberg School of Public Health in a press release issued on the anniversary.

The International Committee of the Red Cross, which has had a campaign called Health Care in Danger since 2011, says the attacks have increased despite the commitments. The slogan of the campaign is “Everyone wounded or sick has the right to health care.”

In Pakistan, doctors supervising the polio vaccine campaigns and police protecting community health workers were shot and often killed in a number of attacks. Many of these attacks took place in areas where wild polio virus is endemic. In August, a suicide attack at Quetta Civil Hospital in Quetta left 74 civilians dead and up to 112 wounded. Though it targeted a group of lawyers and journalists who were mourning a colleague, this bombing was one of the deadliest attacks on a medical facility in the history of the region, according to the report.

In Mali, Human Rights Watch reported that on at least six occasions, ambulances and other vehicles used to transport patients and deliver health care were attacked or robbed. In four of these incidents, sick passengers, drivers and health workers were forced out of the vehicles and robbed and the vehicles stolen. In another incident, an improvised explosive device struck an ambulance that was headed to the scene of another IED attack that killed two peacekeepers.

Syria was the worse country in terms of intensity and impact of the attacks. Physicians for Human Rights reported 108 attacks on health facilities in 2016, most by the country’s own military and Russian forces, and the death of at least 91 health workers.

These are just a few examples of the many tragic incidents in 23 countries detailed in the report.

It is clear that these attacks can have profound effects on the availability of health care. They result in:

Suspension of health programs

        • Degradation of the health infrastructure
        • Exodus of health workers concerned about their security
        • Outbreaks of disease and illness and inability to treat existing conditions

 

Accountability for such reports is largely absent, according to the report. A review by Human Rights Watch of 25 major incidents of attacks on health care between 2013 and 2016 found that either no investigations at all were pursued, or the investigations were inadequate.

As bad as the situation is, the numbers noted in the report may only be the tip of the iceberg because there are surely many attacks that go unreported. And the danger goes beyond the health workers who bear the initial brunt of the attacks.

“Although attacks on health workers are obviously dangerous for the workers themselves, they are also a danger to the communities they serve,” said Laura Hoemeke, director of communications and advocacy at IntraHealth International, one of the key members of the coalition. “If they do survive the attacks, many flee their communities and countries, leaving behind people with even less access to health care. This limited access has a particularly negative impact on maternal, newborn and child health.”

It is bad enough that anyone, anywhere has to do without health care. But to deny healthcare to those living in a state of war or unrest is unconscionable. As The Lancet commented, “One attack on a health worker is one too many.”

Tremendous Progress Against Malaria Seen But Challenges Remain

25th Apr 2017

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Twins Dorcas and Deborah Bendak, 7, under their mosquito net at their home in Musoma, Tanzania. Insecticide-treated bednets have become the cornerstone of malaria prevention efforts. © 2016 Riccardo Gangale/VectorWorks, Courtesy of Photoshare

 

By David J. Olson

When I was a young development worker, I engaged in high risk behavior one night in a village in Mali: I slept without a mosquito net. A week or so later I contracted malaria.

Of all the diseases I have written about here, malaria is the only one with which I have personal and intimate experience. And it was not pleasant. It was so debilitating, so sapping of my energy, I remember not caring whether I lived or died.

Fortunately, I was an otherwise healthy young male and bounced back briskly after a week or so of misery. In fact, I have lived long enough to see the beginning of the end (or at least the decline) of this global killer: In December, the World Health Organization (WHO) released the World Malaria Report 2016 in which it estimated that 1.3 billion fewer malaria cases and 6.8 million fewer malaria deaths occurred between 2001 and 2015 than would have occurred had incidence and mortality remained the same. About 97% of those deaths averted were for children under five years (who are most vulnerable to the disease, along with pregnant women).

Buried on Page 50 of the report is the gist of what makes this news so exciting: In WHO’s Africa Region, these reduced malaria mortality rates have translated to a rise in life expectancy at birth of 1.2 years, accounting for 12% of the total increase in life expectancy of 9.4 years, from 50.6 years in 2000 to 60 in 2015.

This means more children many more children will survive the perils of childhood in Africa and go on to lead productive lives as adults. This makes malaria control one of the most exciting developments of many encouraging global health trends in recent years.

Today we mark World Malaria Day with the message “Let’s close the gap” in malaria prevention. It’s a time to celebrate the tremendous accomplishments to date, but also to remember how many challenges remain. For example, an estimated 43% of people at risk in sub-Saharan Africa are still not protected from malaria, according to WHO. And there were still 212 million cases of malaria worldwide in 2015.

Dr. Richard Cibulskis, coordinator of Evidence and Economics of the WHO Global Malaria Programme, told Global Health TV that we have good reason to be optimistic about the fight against malaria.

“We’ve had huge success in bringing down malaria incidence and mortality rates over the last fifteen years. We have effective tools to prevent, diagnose and treat the disease, and coverage of these tools has been massively scaled up in many countries. There are exciting new technologies under development, and more countries than ever are making progress towards elimination.”

“But there are also some worrying trends, especially the fact that global funding seems to be flat-lining. We can eliminate malaria, but only if we can continue to harness the financial and political will needed to accelerate progress and make new and existing tools available to all who need them.”

Insecticide-treated bed nets are one of the biggest successes in malaria control. The World Malaria Report found that 53% of the population at risk in Sub-Saharan Africa slept under a net in 2015 compared to 30% in 2010. Furthermore, WHO found that people who slept under nets had significantly lower rates of malaria infection than those who did not use a net.

And it was announced yesterday that the world’s first vaccine against malaria will be tested in Ghana, Kenya and Malawi in 2018. The vaccine has the potential to save tens of thousands of lives but it is unclear if it is feasible to get parents to bring their babies in four separate times to get the required doses.

Malaria control has had solid bipartisan support in the U.S. for 15 years. The U.S. government – the largest donor to global malaria efforts – has increased its support from $146 million in 2001 to $861 million in 2016. Funding really took off after former U.S. President George W. Bush launched the President’s Malaria Initiative in 2005.

Last month, U.S. President Donald Trump released a proposed budget that calls for close to a one-third reduction in foreign assistance. We don’t know how those cuts – which still have to be approved by a dubious Congress – would affect malaria control but it does cause concern.

What we do know is that President Trump has announced plans to meet U.S. commitments to the Global Fund for AIDS, TB and Malaria, according to this analysis by Friends of the Global Fight.

The WHO’s Global Technical Strategy for Malaria calls for malaria to be eliminated in at least 35 countries by 2030. Dr. Cibulskis call this “an ambitious but achievable target.”

“But even if this target is achieved, it could still leave us with more than 50 countries in which malaria is endemic,” he says. “A challenge will be maintaining robust funding and political commitment as we continually make progress towards this goal.”

One of the problems the malaria control community worries about is that once cases and deaths have decreased and the disease seems like less of a threat, funding for malaria could be cut.

“History has shown us that we must keep our levels of investment high, or risk a resurgence of the disease and a reversal of progress made to date,” says Dr. Cibulskis. “We cannot let up in our efforts until we get the job done.”

Promoting Contraceptives To Adolescents in Mexico? Make the Campaigns Fun

21st Mar 2017

Monserrat, Ariatne and Isis and their children visit a RED DKT clinic in the Iztapalapa borough of Mexico City to find a contraceptive to space the birth of their next child. Photo: David J. Olson

Monserrat, Ariatne and Isis and their children visit a RED DKT clinic in the Iztapalapa borough of Mexico City to find a contraceptive to space the birth of their next child. Photo: David J. Olson

By David J. Olson

MEXICO CITY, Mexico I met the three young women at a reproductive health clinic in Iztapalapa, the most populous and fastest-growing borough of Mexico City, with a population of 1.8 million on the eastern side of the capital city.

Ariatne and Isis, both 20 years old, each have one child. Monserrat was their aunt, but didn’t look much older. She had three children. All of them were looking for a way to space the birth of their next child. One of them wanted to wait five years; another, ten years.

All of them had chosen intrauterine devices (IUDs) as their contraceptive, one of them told me, “because they are comfortable and secure.”

Although unplanned pregnancy is a big problem in Mexico (and the rest of Latin America), good sexual and reproductive healthcare is hard to come by in Mexico, especially for adolescents, according to a recent study.

Almost three-quarters of pregnancies among adolescents aged 15-19 in the region are unplanned, according to the Guttmacher Institute, and about half of those end in abortion. Among all women 15-19 who need contraceptives, 36% of them are not using a modern method. The unmet need is highest in Central America, where 46% of sexually active adolescents who want to avoid pregnancy are not using modern contraceptives.

DKT México, a non-governmental organization that uses social marketing to prevent HIV and promote contraception in Latin America and the Caribbean, has learned some lessons about how to promote contraception to young people after success in promoting condom use but failing to do the same with contraceptives after they took a more traditional approach.

In 2015, DKT México launched a family planning campaign focused on increasing awareness of pregnancy among teenagers and young adults. They opted for a serious, medical campaign in traditional pharmaceutical company style they talked in the negative and expounded on the myths of various contraceptive methods.

The campaign failed. Few young people attended their events or engaged their digital media. Their messages did not resonate with the audience they were trying to reach. This translated into poor contraceptive sales.

At the same time, they were having a highly successful Prudence condom campaign with well attended events a Facebook page with 2 million followers and a Twitter account with 47,500 followers. Their condom sales tripled between 2012 and 2016.

The contrast between the two campaigns strongly suggested that they had to apply the same fun strategy of openly talking about sex in their family planning work as they were doing in their condom work. So they made major changes to their campaign:

    •They avoided talking in the negative and focusing on myths. Instead, they focused on the positive results of contraception.

    •They realized that most Mexicans think of babies as a blessing from God, and it doesn’t help to talk of “unwanted” pregnancies, so they changed to “unplanned pregnancy.”

    •They shifted the focus to how these unplanned pregnancies can interrupt education, travel and careers, things about which young people care very much.

    •They stopped using the term “family planning” and started talking about “life planning.” Young people do not think in terms of family planning; they are more interested in planning their education, careers and other life goals. This is true not only in Mexico but in other countries as well, something I wrote about here.

“In short, we stopped being preachy and started being fun, adopting the same entertaining messages and approaches we were using to market Prudence condoms at schools, concerts and fairs,” said Karina de la Vega Millor, director general of DKT México. “The main message became ‘Have sex, have fun, but use double protection against a sexually-transmitted disease or an unplanned pregnancy that will change the course of your life.’”

DKT México created “Planficame Esta” (“Plan me this”), a lively digital platform with a website, and a presence on Facebook, Instagram and YouTube.

“These tools give fun messages about the importance of having a life plan and avoiding pregnancy until you are ready, said Millor. “There are plenty of ribald jokes, frank discussions and flirty talk full of double entendres to engage our audiences. Our Facebook page now has more than 1.1 million followers, and more engagement than any Facebook page dedicated to contraception in all of Latin America.”

The clinic I visited in Iztapalapa, where a majority of the residents are poor to middle class, is affiliated with RED DKT (DKT Network) which DKT started in Mexico a year ago to improve sexual and reproductive health and encourage use of long-acting reversible contraceptives like IUDs.

The bottom line is that DKT México learned from the mistakes of its first campaign. This new campaign promotes life planning, not family planning. It has resulted in more young people viewing DKT websites and social media platforms, sharing information with their friends and coming to DKT events and clinics to get information and products to help plan their lives.

And more of them are actually using contraception to avoid unplanned pregnancy. Millor says that DKT México has increased almost eight-fold its number of couple years of protection (the amount of contraception to protect a couple for one year) between 2012 and 2016. She said they estimate they contributed about 4% of all the couple years of protection in Mexico in 2016, according to DKT calculations. That may not sound like a lot until you realize that Mexico is the tenth most populous country in the world, with a population of 129 million.

DKT México is now expanding into Central America, the Caribbean and northern South America and it will apply the lessons it has learned in Mexico to these new countries.

Though Preventable, Cervical Cancer Causes Half Million Cases Per Year

28th Feb 2017

Four volunteers of ICANSERVE Foundation exhort women to take advantage of free cervical and breast cancer screening at an event in the Philippines. Photo: ICANSERVE Foundation.

By David J. Olson

Over 16 years ago, Sally Kwenda survived colon cancer and HIV, and then lost her husband and two children to AIDS-related illnesses.

“Just when I thought I was done with the hurt and the pain, I was diagnosed with stage II cervical cancer,” she recalls. “Many of those I have met on this journey have either passed away or are worse off than me. Many of them got their diagnoses when it was too late to change the tide. Yet cancer does not have to be a death sentence. My experience reveals that cancer is curable.”

Cervical cancer is the most common cancer among women in Sally’s home country of Kenya as well as in 38 low- and middle-income countries, mainly in sub-Saharan Africa, according to the American Cancer Society (ACS).

The reasons for the high rates of cervical cancer in Kenya, according to Deborah Olwal-Modi, executive director of the Kenya Cancer Association, include lack of knowledge and awareness, inadequate facilities for prevention and treatment, economic barriers, and co-morbidity of cervical cancer and HIV/AIDS. For example, almost all women (97 percent) do not know that a virus causes cervical cancer, according to a new study among women in major Kenyan cities.

Worldwide, there were an estimated 528,000 new cases and 266,000 deaths from cervical cancer in 2012, with more than 86% of those deaths occurring in less developed countries. Last year in India, it killed almost 70,000 women. And the situation is getting worse: The number of deaths is projected to rise to 443,000 annually by 2030, according to the World Health Organization (WHO).

And yet vaccination, early screening and treatment of precancerous lesions can prevent most cases of cervical cancer. In fact, ACS says cervical cancer is one of the most treatable cancers. In the U.S., for example, the cervical cancer death rate has declined by more than 50 percent over the last 30 years.

“HPV vaccination given to adolescent girls and inexpensive screening techniques replacing the too expensive, too complicated Pap smear could bring cervical cancer under control within a generation,” said Sally Cowal, senior vice president of global health at ACS.

Virtually all cases of cervical cancer are caused by the Human Papillomavirus (HPV) infection through sexual contact, and the optimal time for acquiring infection is shortly after becoming sexually active. That is why the WHO recommends vaccinations for girls aged 9-13 which WHO says is the most cost-effective measure against cervical cancer

Yet some parents seem to have a problem taking their young daughters in for a vaccination against HPV to protect them against infections which may seem far in the future and which is transmitted sexually. In the U.S., a 2014 study published by the U.S. Centers for Disease Control and Prevention showed that only 39.7 percent of girls aged 13-17 had received the full three doses of the HPV vaccine, much lower than the 87.6 percent of boys and girls of the same age that received tenanus-diptheria-acellular pertussis vaccinations.

In a report launched in conjunction with World Cancer Day on Feb. 4, the WHO said that the early diagnosis of cancer and prompt treatment, especially for breast, cervical and colorectal cancers, would lead to more people surviving the disease and cutting treatment costs. “Not only is the cost of treatment much less in cancer’s early stages, but people can continue to work and support their families if they can access effective treatment in time,” said the report.

How much would it cost to implement HPV vaccination in developing countries? Based on a study supported by ACS, Harvard T.H. Chan School of Public Health experts have estimated that approximately 60 million girls in 17 high-burden, low-income countries could be immunized over five years at a cost of approximately $800 million or $13.40 per fully immunized girl. If the U.S. government committed to funding 20% of that, it would equate to about $160 million, or $32 million per year.

But current funding is not well aligned with the actual burden of disease in countries where the U.S. governments supports health programs. “While more than a quarter of deaths in priority low- and middle-income countries is from chronic diseases, such as cancer,” says the ACS, “virtually no funding is provided to prevent those deaths.”

World Cancer Day was Feb. 4 and the theme was “We can. I can” and explores how everyone can do their part to reduce the global burden of cancer.

Certainly Sally Kwenda is playing her part. She is now a Relay for Life “Hero of Hope” (Relay for Life is an annual athletic event to raise funds and awareness for cancer education) with the Kenya Cancer Association and spends her time connecting with other cancer survivors and using the knowledge she has acquired to empower and encourage them.

“The best warrior is not the one who always wins the battle but the one who is not afraid to go back to the battlefield. My plea to every single person is: Now is the time to act. It is time to beat this disease. I strongly believe this is possible.”

The Lancet has just published a special issue on breast and cervical cancer on Feb. 25, 2017.

Cervical Cancer Fact Sheet

Cervical Cancer Fact Sheet

Global Health Film on Refugee Struggle Continues to Gain Global Recognition

24th Feb 2017

London, UK – Back in May 2016, Global Health TV travelled to the heart of ‘Tent City’ one of Lebanon’s most over populated refugee regions – The Bekaa Valley.  Working with World Vision, Global Health TV witnessed first-hand how the Lebanese Cash Consortium, a humanitarian aid coalition, provided financial assistance to Syrian refugees – empowering them to buy items fundamental to their survival, such as clean water, food, medicine and shelter.

Living Below the Line: Life as a Refugee in Lebanon is a Global Health TV film that shares the story of Hajar, a mother of four, who fled her home town of Al Kusayr (Syria) with her children, after her husband went missing during heavy shelling. ‘We were living in our own house, now we are living in a tent… our life here has its effects on the children, it reflects on their faces. It effects their health too’ she said. Hajar is one of the many recipients of the financial assistance provided by the Lebanese Cash Consortium, of which World Vision is a member of.

“There is no doubt that cash modality in the humanitarian response is one of the most efficient, effective, fast, innovative, creative and dignifying way to assist vulnerable population. The consortium along with ECHO (European Commission of Humanitarian Aid and Civil Protection) and DfID (Department for International Development) are trusting people with money and trusting that they know better what they need most,” said Patricia Mouamar, Communications Manager at World Vision International.

Since its debut at the first ever World Humanitarian Summit, organised by World Health Organization (May 2016), the film continues to gain recognition – awarded gold at the 2016 MarCom Awards and more recently receiving an honourable mention at the 2017 AVA Digital Awards.

Through raising the profile of this humanitarian issue, Living Below the Line: Life as a Refugee in Lebanon, highlights the importance of co-ordinated efforts, particularly between aid agencies to help those who need it the most. Now more than ever, this joint collaboration is needed to address the growing number of refugees, asylum-seekers and displaced people around the world which has now exceeded 65 million, according to The UN Refugee agency.

Watch the full story of Hajar and the situation in Lebanon below

 

 

About

Lebanese Cash Consortium provides assistance that empowers refugees to make their own decisions with dignity. www.lebanoncashconsortium.org

World Vision International is a global Christian relief, development and advocacy organisation dedicated to working with children, families and communities to overcome poverty and injustice. Visit www.wvi.org for more information.

-END-

As Infectious Disease Falls, Chronic Disease Increases; Possible Solutions Emerge

31st Jan 2017

A patient undergoes a full physical exam as part of an attempt to detect and treat non-communicable disease supported by Novartis Access. Photo: Bedad Mwangi

A patient undergoes a full physical exam as part of an attempt to detect and treat non-communicable disease supported by Novartis Access. Photo: Bedad Mwangi

 

By David J. Olson

As 2017 begins, we celebrate the fact that many diseases of developing countries have been significantly reduced in recent years. The numbers of people suffering from HIV, malaria and tuberculosis are in decline.

But as communicable diseases wane, non-communicable diseases (NCDs) wax (like cancer, diabetes, cardiovascular and chronic respiratory diseases).

This was hammered home by the Institute for Health Metrics and Evaluation (IHME) of the University of Washington which, just in the last two months, released three new reports that provide further evidence of this trend:

• Almost 20% of global deaths in 2015 were linked to elevated blood pressure, according to the latest Global Burden of Disease study. The number of people in the world with high blood pressure, including hypertension, has doubled in the past two decades, putting billions at increased risk for heart disease, stroke and kidney disease.

• Cancer is growing almost everywhere in the world but the greatest increase between 2005 and 2015 occurred in the poorest countries that are least equipped to deal with it, according to a new analysis.

• 30% of all deaths from diabetes worldwide occur in the poorest countries bringing a double burden of disease – from communicable and non-communicable disease – to many countries in Africa, according to a new IHME report. Women often bear most of the burden.

Of course, NCDs are not a new problem. However, they are increasing both in scale and visibility because of the transition from low-income to middle-income status, the influence of globalization on diet and consumption patterns and greater longevity as people increasingly survive childhood illness and communicable disease, according to an analysis by the Kaiser Family Foundation.

Despite the rising tide of NCDs, though, little money has been invested to prevent and treat them. In Financing Global Health 2014, IHME said that development assistance for health (DAH) directed towards NCDs is one of the smallest health focus areas they estimate and was only $611 million in 2014, just under 2% of total DAH. The first graph on page two of this brief shows just how little NCDs are funded compared to communicable disease and child health.

“The productivity loss for NCDs is estimated to be $500 billion annually yet almost no donor funding is being deployed against them,” said Dr. Harald Nusser, global head of Novartis Access and Novartis Malaria Initiative. “We need robust funding for both communicable and non-communicable disease, and more robust health systems in general to start turning our efforts towards NCDs while not relenting in the fight against AIDS, malaria and tuberculosis.”

“NCDs share all the ideological and social justice issues of HIV but cause 30 times more deaths and receive 17 times less funding,” writes Luke N. Allen and Andreas B. Feigl in a new commentary in The Lancet Global Health.

Even communicable disease experts see how the disease burden is shifting to NCDs. Charles Nelson, chief executive of the Malaria Consortium, talks about how malaria death have fallen between 2000 and 2015 while NCDs are rising. Nelson said disability-adjusted life years (DALYs), which is a measure of overall disease burden, coming from communicable maternal, perinatal and nutritional diseases is decreasing while DALYs from NCDs is increasing, said Nelson. This is true globally, as well as in Africa and Southeast Asia.

Kenya seems to be the focus of much of the research as well as some of the earliest attempts to deal with NCDs in Africa.

A report on the burden of disease in Kenya found that the country has made tremendous progress in dealing with communicable disease and maternal and child health but that the burden of NCDs was growing, with the health loss from NCDs growing from 19% in 2000 to almost 30% in 2013.

Three new efforts, all led by pharmaceutical companies, are trying to address NCDs in Kenya:

• In 2015, Nusser helped launch Novartis Access which makes 15 on- and off-patent medicines available to treat NCDs at $1.00 per treatment per month.

• AstraZeneca’s Healthy Heart Africa program conducted one million hypertension screenings in Kenya, opened over 250 health facilities, trained over 2,600 health care workers, diagnosed close to 150,000 patients with high blood pressure and started treatment for 25,000 patients in its first year.

• Novo Nordisk is expanding its Base of the Pyramid Project, a sustainable initiative rolled out in 2010 to facilitate access to diabetes care for the working poor in low- and middle-income countries. The project has screened more than 20,000 people for diabetes.

And a major initiative involving 22 biopharmaceutical companies just launched Access Accelerated, a global initiative to increase access to NCD prevention and care in low- and lower-middle income countries, at the World Economic Forum on Jan. 18. Access Accelerated is supported by $50 million in funding and a pledge of increased individual company programs focused on NCDs.

The NCD movement has long been hobbled by its unwieldy name – non-communicable diseases. “A name that is a longwinded non-definition, and that only tells us what this group of disease is not, is not befitting of a group of diseases that now constitute the world’s largest killer,” writes The Lancet Global Health, which calls for a change in terminology (and offers a few suggestions) to bring needed and deserved attention to these diseases.

 

 

The End of Trachoma, World’s Leading Cause Of Preventable Blindness, Is in Sight

13th Dec 2016

This woman, who has just been examined by a local health worker at a clinic in Ressa Kebele, Kallo District, Amhara, Ethiopia, will receive trichiasis surgery. The arrow indicates which eye will be operated on. Credit: The Carter Center.

This woman, who has just been examined by a local health worker at a clinic in Ressa Kebele, Kallo District, Amhara, Ethiopia, will receive trichiasis surgery. The arrow indicates which eye will be operated on. Credit: The Carter Center.

By David J. Olson

In 1988, as a young development worker for Lutheran World Relief in Mali, I was showing a group of American Lutherans our development projects in Dogon Country, when we came across a tragic situation a young boy with a severely inflected eye, where he had lost his sight, with menacing flies hovering around the other, still good eye.

It was a heart-wrenching scene for these people, most of whom were on their first trip to Africa. One woman took pity on the boy and, after returning to the U.S., raised money for his treatment. I took the boy to the best hospital in the country in the capital Bamako. Doctors removed his infected eye, and replaced it with a glass eye. Without treatment, he surely would have gone completely blind.

That was my first exposure to trachoma, the world’s leading infectious cause of blindness in the world. Trachoma a bacterial eye infection found in poor, isolated communities lacking basic hygiene, clean water and sanitation – continues to plague Mali and 40 or so other countries.

What is trachoma? It is a disease of the eye caused by infection with the bacterium Chlamydia trachomatis that is spread through personal contact and by flies that have been in contact with discharge from the eyes or nose of an infected person. If the infection persists, the inside of the eyelid becomes so scarred that it turns inward and causes the eyelashes to rub on the eyeball, causing pain, discomfort and permanent damage to the cornea.

The World Health Organization estimates that trachoma is responsible for the blindness or visual impairment of 1.9 million people in 42 countries, with just over 200 million people at risk of trachoma blindness.

The Carter Center, best known for its work on Guinea worm (which is close to elimination), is now focusing on its next miracle – the elimination of blinding trachoma by 2020. The Center works to control and prevent trachoma in six of the 31 countries actively implementing a prevention strategy (Ethiopia, Mali, Niger, Sudan, South Sudan and Uganda).

Just last month, WHO declared Morocco to be the eighth country to eliminate trachoma as a public health problem. The other countries are China, Gambia, Ghana, Iran, Mexico, Myanmar and Oman.

The Carter Center says that in order to eliminate blinding trachoma, all four components of the SAFE strategy must be implemented: Surgery for advanced disease, Antibiotics to clear infection, Facial cleanliness and Environmental improvement to reduce transmission (particularly, improving access to water and sanitation).

In September in Washington, D.C., the Carter Center screened a documentary film from award-winning producer Gary Strieker and Cielo Productions called “Trachoma: Defeating a Blinding Curse,” in which a film crew followed Carter Center staff and other health professionals around Ethiopia for seven years in the Amhara Region, Ethiopia, the most endemic region of the most endemic country.

Strieker, a former CNN correspondent based in Africa, talked about the power of the story of the fight against trachoma.

“Most of the stories I covered in Ethiopia over the years were not very encouraging – famines, droughts, revolutions,” he recalled. “Ethiopia was always in the portfolio – one of those hopeless cases where you could be sure that whatever was coming out of Ethiopia would be bad. People had no hope. You could see it wherever you went.”

“But as we watched the trachoma campaign develop, the sustained effort by the government and the people to carry this out, we saw thousands of health workers mobilized, so much enthusiasm and making it happen in front of our eyes, year after year. They set an example for the rest of Africa and the developing world. It’s a great testament to what can be done if the government has the political will and actually reaches the people and gets them to work in their own interests. It’s been so encouraging and such a wonderful story.”

Kelly Callahan, the Carter Center director of the Trachoma Control Program, said that the trachoma campaign success happened because it was done with a “bottom-up structure.”

“The government is not telling people what to do, when to do it and how to do it,” she said. “It’s the people that are driving the force. If the people are driving it, they own it, they feel empowered and they feel they’re doing something together. If the community doesn’t own the program, then it’s not sustainable and it will not improve their lives.”

Trachoma foes believe the goal of elimination by 2020 is realistic even though much works remains to be done. A massive mapping exercise was conducted in 2013 to help understand better the scale of the problem outside of the Carter Center-assisted countries. Since then, activities have increased in most of these places. The Carter Center-assisted countries should achieve 2020 goal, Callahan said, through a strong commitment of the government in each country, the communities, the partners and the global alliance.

Trachoma control is not only the moral thing to do, it makes good economic sense. Trachoma prevention and treatment is one of the best buys in global health, according to Paul Emerson of the International Trachoma Initiative. Every dollar invested in trachoma reaps thousands of dollars in savings, Callahan said.

Callahan thinks the elimination of trachoma will have an impact beyond trachoma. “If someone’s suffering from trachoma, they’re probably suffering from river blindness, probably co-endemic for schistosomiasis, soil-transmitted helminths and lymphatic filariasis. If you pile on these diseases, their immune systems are so suppressed that HIV, TB and malaria – the big killers – can come in. So if we can get rid of Guinea worm and trachoma and pluck every single one of these diseases, imagine immune systems that are not suppressed from neglected tropical diseases. Just think of the quality of life. That’s immeasurable.”

Golden Recognition for Living Below the Line: Life as a Refugee in Lebanon

6th Dec 2016

LebanonRefugees200516MED

Global Health TV has been recognised with gold at the 2016 MarCom Awards for the film Living Below the Line: Life as a Refugee in Lebanon. It debuted in May at the first ever World Humanitarian Summit, organised by World Health Organization. Living Below the Line was one of 6,500 entries submitted to the MarCom Awards from across the globe and highlights the situation in Lebanon and the importance of joint collaboration between agencies to help those in need.

Executive Producer Cath Sheehan worked with World Vision and with a local crew to capture the reality for Syrians who escaped from conflict, and are now living in a Lebanese refugee camp.  World Vision is one of six aid agencies working together in the region as a part of the Lebanese Cash Consortium (LCC).  Providing refugees with financial assistance, the LCC enables them to identify and prioritize the issues most pressing to them and their family.

“There is no doubt that cash modality in the humanitarian response is one of the most efficient, effective, fast, innovative, creative and dignifying way to assist vulnerable population. The consortium along with ECHO (European Commission of Humanitarian Aid and Civil Protection) and DfID (Department for International Development) are trusting people with money and trusting that they know better what they need most,” said Patricia Mouamar, Communications Manager at World Vision International.

“Recipient of the cash assistance are optimizing the use of money, like Aida a Syrian mother I met in Lebanon, who managed to use the cash to pay the cab 20,000 LBP (13USD) and ran to the emergency room, when her seven year old child was in an urgent need of hospitalization when boiled water caused him severe skin burns,” said Patricia Mouamar.

 

About

Global Health TV is a platform to communicate the work of the global health community, sharing stories that advance knowledge and response to global health issues. www.globalhealthtv.com

Lebanese Cash Consortium provides assistance that empowers refugees to make their own decisions with dignity. www.lebanoncashconsortium.org

World Vision International is a global Christian relief, development and advocacy organisation dedicated to working with children, families and communities to overcome poverty and injustice. Visit www.wvi.org for more information.

Please contact: Sally Nelson, Global Health TV, globalhealthtv@websedge.com

Polio’s Days Are Numbered As Teams Close in on Last Few Cases in 3 Countries

23rd Nov 2016

By David J. Olson

Khuram and Latif, on left, were two of the polio heroes of Pakistan honored at a World Polio Day event at the Pasteur Institute. Khuram works for Sanofi Pasteur, the main polio vaccine supplier; Latif is a polio vaccinator who was shot in 2012. Jim Costello, on right, contracted polio in 1958. His lungs are 75% paralyzed and he uses a medical ventilator 18 hours a day. He has fought for polio survivors since 1993 and was also honored as a polio hero. Photos by David J. Olson

Khuram and Latif, on left, were two of the polio heroes of Pakistan honored at a World Polio Day event at the Pasteur Institute. Khuram works for Sanofi Pasteur, the main polio vaccine supplier; Latif is a polio vaccinator who was shot in 2012. Jim Costello, on right, contracted polio in 1958. His lungs are 75% paralyzed and he uses a medical ventilator 18 hours a day. He has fought for polio survivors since 1993 and was also honored as a polio hero.  Photos by David J. Olson

 

By David J. Olson

PARIS, France In 2012, Latif and his colleague were vaccinating children against polio in Pakistan when they were shot by extremists. Latif was shot in the leg. He had 11 metal rods inserted into his leg and was hospitalized for three months. His colleague died. Today, fully recovered and undeterred, Latif (his surname is withheld to protect his security) continues his anti-polio crusade in northwestern Pakistan.

Jim Costello, 73, contracted polio at the age of 15. It paralyzed his upper body: He has triple curvature of the spine, wears a spinal brace and has no use of his arms. His lungs are 75% paralyzed and he uses a medical ventilator for about 18 hours daily. He lives at home in Dublin, Ireland with his wife Delia, “my beloved partner of over 30 years,” on the weekends. During the week, he is in the hospital where he still uses an iron lung. Despite these limitations, he has led a productive life in the retail clothing business and in support of polio survivors. Since 1993, he has served as chairperson and board member of Post-Polio Support Group Ireland

Latif and Costello were two of five people honored as “polio heroes” at a World Polio Day event Oct. 24 at the Pasteur Institute here sponsored by Sanofi Pasteur and Rotary International, two organizations deeply invested in the fight against the disease. Meet Latif in this video and Khuram (an employee of Sanofi Pasteur) in this video (videos from Sanofi Pasteur/AKS Films).

Participants heard experts say that the world is tantalizingly close to eliminating polio, and that elimination could happen in 2017. As of last week, there were only 32 remaining cases of wild poliovirus 16 in Pakistan, 12 in Afghanistan and 4 in Nigeria.  We are on the brink of eliminating the second human disease in history (smallpox, in 1980, was the first).

It is true that all three countries have security challenges. But in Pakistan, the country with the largest number of remaining cases, the security situation has improved markedly since 2014.

“There were close to half a million kids not reachable due to insecurity in 2014,” said Dr. Mufti Zubair Wadood, technical officer for the Global Polio Eradication Initiative at the World Health Organization (WHO) and former head of the WHO polio program in Pakistan. “Since then, the situation has been improving and right now there are almost no areas of the country that are not accessible. That has resulted in a significant drop in the number of cases. Pakistan deserves a huge pat on the back at a time when things were dire.”three countries have security challenges. But in Pakistan, the country with the largest number of remaining cases, the security situation has improved markedly since 2014.

Wadood believes the next six months presents an excellent opportunity because this cooler period is when the vaccine works best and the virus is not transmitting at a high rate. “If good campaigns are implemented in the next 3-6 months, there is no reason we cannot stop it in late 2016 or early 2017,” said Wadood.

The polio eradication campaign is the largest public health program in history. For nearly 30 years, national governments, WHO, Rotary International, the U.S. Centers for Disease Control and Prevention and UNICEF have worked on this issue. More recently, the Bill and Melinda Gates Foundation joined the effort.

Sanofi Pasteur is, by far, the biggest supplier of polio vaccine in the world. It has provided 6 billion doses of the oral polio vaccine over the last decade and more than 1 billion doses of the inactivated polio vaccine, through injection, which will protect people once polio is eradicated.

But polio vaccination will continue for years after eradication, said David Loew, executive vice president of Sanofi Pasteur. Loew said that Sanofi is even considering building a second factory in order to develop the production capacity necessary to produce the injectable version.

Polio eradication is not only a global health success but also an economic success. Eradication is expected to save between $40 and $50 billion during the period 1988 to 2035, according to Dr. Kimberly Thompson, professor of Preventive Medicine and Global Health at the University of Central Florida. “Polio eradication represents a gift from our generation to future generations.”

Elimination may be near but Latif, the Pakistani polio hero, is not ready to declare victory quite yet. “I want the children of my country to be healthy and protected from polio. I have participated in this fight from the beginning and I want to continue to the end, to see a polio-free Pakistan.”

Did he consider giving up after extremists shot him in 2012? “No, I never thought of that,” he said. “As a matter of fact, I don’t connect the pain I felt with the work I do. They are two different things in my mind.”

Costello, the indefatigable polio survivor wanted to make two points:

If the people who attack vaccination teams could see me and people like me, is that really how they would like their own children to live their lives?

“I would like to appeal to the WHO, Rotary International and other organizations working to eradicate polio. When their job is done, which I know will be soon, would they please consider turning their valuable efforts towards the millions of polio survivors, particularly in underdeveloped countries, that now face the problems associated with post-polio syndrome?”

 

New Test to Detect HIV In Babies Boosts Hope Of Meeting UN Targets

25th Oct 2016

Dr. Landon Meyer of the University of Cape Town takes a blood sample from the heel of an infant using the Alere q HIV-1/2 Detect rapid HIV test. The results become available in less than one hour.

Dr. Landon Meyer of the University of Cape Town takes a blood sample from the heel of an infant using the Alere q HIV-1/2 Detect rapid HIV test. The results become available in less than one hour.

By David J. Olson

When Saquina, a 38-year-old single mother living in Nacala Porto, Mozambique, learned she was HIV positive while pregnant, she thought her life was over. Instead, she decided to accept her HIV status and follow the advice of the nurse who counseled her.

She did not miss any visits to the health center. She took the pills that helped prevent transmission of the virus to her unborn child. She participated in support groups with other HIV-positive mothers. When her son Frenchou was born, she gave him medication every day and breastfed him exclusively for six months.

When he was two years old, Frenchou was tested for HIV and found negative another of many recent successes in the prevention of mother-to-child transmission (PMTCT), according to the Elizabeth Glaser Pediatric AIDS Foundation.

Between 2009 and 2015, there was a 60% decline in new HIV infections in children in the 21 priority countries, according to a UNAIDS report released in June. Seven of those countries reduced infections by more than 70%. A total of 1.2 million new infections among children were averted in these countries.

But if you thought thought that all is now well with PMTCT, and that we can move on to other HIV challenges, you would be mistaken. While a 60% drop is certainly encouraging, it is significantly below the 90% target set by the World Health Organization (WHO). UNAIDS has set a goal of eliminating all new HIV infections among children by 2020 while ensuring that 1.6 million children have access to HIV treatment by 2018.

Every day, an estimated 400 children are infected with HIV. When children with HIV are not diagnosed and treated promptly, as many as one-third will die before their first birthday and half before their second birthday.

But to achieve this goal, early infant diagnosis has been a major stumbling block. Up to now, infant testing has imposed a lag time between the test and the results of 3 to 6 weeks.

We know that if mothers and babies have to return to the clinic for test results weeks later, they are less likely to get the results and start treatment. “About 50 percent of infants who are tested do not receive their test results and, of those children who test positive, 40 percent never receive treatment,” notes the Elizabeth Glaser Pediatric AIDS Foundation.

That’s why a new technology for testing infants in less than one hour is so exciting. Alere, a U.S.-based company in rapid diagnostic products and services, says the test called the Alere q HIV-1/2 Detect is the first ever molecular diagnostic that identifies HIV-1 and HIV-2 in a health facility (Alere calls this “point-of-care testing”) in less than one hour. The technology allows HIV-positive babies to be put on treatment immediately. It also eliminates the problem of mothers not returning to the clinic for their test results.

Alere believes point-of-care testing will accelerate testing of infants, especially in South Africa, which has the highest HIV burden in the world. Currently, an estimated 11.2% of the population is living with the disease. South Africa is piloting the test in two health centers in the Western Cape.

“Currently, most newborns in developing countries are screened for HIV infection via dry blood spot testing, but because health workers have to wait 3 to 6 weeks for results many potentially HIV-positive infants are lost to follow-up and remain untreated,” said Dr. Landon Meyer, a professor at the School of Public Health and Family Medicine at the University of Cape Town. “The ability to provide to a patient’s mother a definitive test result when before we would often conduct a test and mothers wouldn’t come back the ability to provide that on-site within 52 minutes really is an epiphany. It’s a revelation.”

“There have been massive successes in PMTCT over the last decade, particularly in South Africa, but what we realize more and more is that the battle is not won and it’s going to be a very long time before we eradicate pediatric HIV infection, and so technologies like the [Alere] q become more important to us in practice.”

Pilots are also taking place in Malawi and Mozambique, and Kenya is looking at the possibility of using this test.

In June, Alere won prequalification from WHO, meaning the technology can be widely implemented by organizations and governments, and used by health workers to diagnose HIV infections rapidly, allowing for a more timely initiation of anti-retroviral therapy.

Anti-retroviral treatment is very effective in children with HIV, transforming it from a death sentence to a long-term, manageable condition, according to NAM. Many experts believe that treated children will have almost normal life expectancy.

If we can improve diagnostics and treatment, and deliver them to those children who need them, we will have more happy endings, like the inspiring 21-year-old Lerato, from South Africa, who was born with HIV. Now she says “There’s more to life than HIV. It’s not stopping me. I can do anything I want.”

A Long, Hard Road to Reversing Stagnation of Family Planning in Nigeria

27th Sep 2016

DKT Bee Lydia, a community health worker, gives Iya Lekan a Sayana Press injectable contraceptive at her house. She has five children and does not want any more, at least for now.  Photo by David J. Olson

DKT Bee Lydia, a community health worker, gives Iya Lekan a Sayana Press injectable contraceptive at her house. She has five children and does not want any more, at least for now.
Photo by David J. Olson

 

By David J. Olson

LAGOS, Nigeria Lydia, a community health worker for DKT Nigeria, steps carefully as she navigates the grimy streets of Makoko, one of the worst slums of Lagos. She is trying to avoid mud or something worse. The sanitation is abysmal. But Lydia is on a mission to bring contraception to some of the most disadvantaged women in Nigeria.

This day, she calls on Iya Lekan. Although neither Iya, 36 years old, or her husband have regular work or specific sources of income, they have five children to look after.

“I don’t know how many times I have given birth,” she says in Yoruba, the local language here. “I’m tired.”

Iya told Lydia she was ready to start practicing family planning. Lydia presented various options, and Iya chose a three-month injectable called Sayana Press. Lydia immediately gave her the injection in her upper thigh.

Some people think Sayana Press could be a game-changer. It’s a new version of the well-known Depo-Provera injectable contraceptive, but contains 30% less of the active ingredient and can be administered by lesser-skilled health workers. The United Kingdom has already approved it for self-injection.

Last month, I spent an afternoon with Lydia, a member of the DKT Bees, a group of community health workers (CHWs) who focus on family planning in some of the grittiest parts of Lagos. DKT calls their CHWs “bees” because they are like the hard-working insects that go from flower to flower spreading pollen. But instead of pollen, DKT Bees go house to house counseling, educating and dispensing contraceptives.

The road to greater contraceptive use in Nigeria has not been smooth. It’s shocking that the percentage of married women using modern contraception in Nigeria is only 9.8 percent (Nigeria Demographic & Health Survey 2013). That figure is lower than all countries in West Africa except Gambia, Guinea and Mauritania, according to the 2016 World Population Data Sheet, and has has hardly changed in the last ten years. Nigeria has a population of 187 million, making it the seventh largest country on earth. If current trends continue, it will be tied for third, with the United States, in 2050.

Clearly, family planning has stagnated in Nigeria since 1999. The reasons are many but certainly family planning myths and misinformation play a huge role. A DKT outreach worker told me that some of the most common questions she gets from Nigerian women are:

  1. What are the side effects of each method?
  2. Does family planning result in infertility?
  3. Does family planning increase body weight or make me fat?
  4. What do I do if bleeding occurs?
  5. Does contraceptive use predispose me to cancer?

The bottom line is that contraceptives are good for the health of women. In fact, Nigerian health experts blame the low uptake of family planning as one of the reasons why Nigeria still reports high maternal mortality.

The good news is that 16.1% of married women in Nigeria who are not using family planning want to start using it. The figure is even higher among sexually active unmarried women: 21.8 percent of them want to use contraception.

World Contraception Day on Sept. 26 provides a good opportunity to reflect on the current situation and what we can do to improve it in places like Makoko, so that every Nigerian woman who wants contraception can access it.

Decades of research have shown that modest investments in family planning can save lives and improve maternal and child health. And consider that family planning has been proven to be one of the most cost-effective health interventions. In short, family planning improves the economic well-being of families, communities and nations.

DKT Bees are one of the programs of DKT Nigeria, an affiliate of DKT International. DKT came to Nigeria in 2013 to help change the family planning paradigm. Using social marketing, it launched Kiss and Fiesta condoms, Postpill emergency contraception, Levofem oral contraceptive, Sayana Press injectable, Implanon NXT and Jadelle implants, Lydia intrauterine devices (IUDs) and Miso-Fem (Misoprostol). After only three years, it contributed 14% of Nigeria’s contraceptive prevalence rate in 2015.

Dimos Sakellaridis, the country director of DKT Nigeria, says he wants to make affordable contraceptives as easily available in Nigeria as Coca-Cola.

“Like women’s beauty products or hairstyles, modern family planning should be consumer-oriented and easy to understand, access and use,” he says. “When a woman wants to feel beautiful, she walks to a nearby store and buys a beauty product or service. Family planning should be obtained for the same consumer benefits to enable women to feel beautiful by allowing them to manage their fertility and life.”

DKT Nigeria launched a new family planning communications campaign that coincides with World Contraception Day on Sept. 26. The target audience of its campaign is young women ages 18-34 (primary) and young men ages 20-34 (secondary) in the lower middle and working classes of southwest Nigeria. A new website, Honey and Banana, will serve as the central hub of the campaign and will be the destination for other traffic sources, such as Facebook, Twitter and Instagram.

The theme of the campaign is “Be Sharp.” The phrase is common slang that resonates with the target audiences. It means be smart, not dull. It means making the right decisions, especially concerning birth control and contraception, to avoid unwanted surprises.

Almost one in five people living in sub-Saharan Africa is a Nigerian. If enough girls and women are motivated to adopt contraception, the government will meet its goal of reaching 36% contraceptive prevalence rate by 2018, and their health will improve. It all comes down to community health workers like Lydia and the DKT Bees, going from house to house, taking one step at a time, to meet the needs of disadvantaged Nigerian girls and women.

DKT Bee Lydia (center) in the Lagos slum of Makoko, with "Queen Bees" Mary and Julian, registered nurses who supervise the team of Bees. Photo by David J. Olson

DKT Bee Lydia (center) in the Lagos slum of Makoko, with “Queen Bees” Mary and Julian, registered nurses who supervise the team of Bees. Photo by David J. Olson

The Next Great Pandemic: What Will It Look Like and Where Will It Come From

23rd Aug 2016

Pandemic: Tracking Contagions, from Cholera to Ebola and Beyond

Pandemic: Tracking Contagions, from Cholera to Ebola and Beyond

By David J. Olson

A few years ago, in a survey by epidemiologist Larry Brilliant, 90 percent of epidemiologists said that a pandemic that will sicken 1 billion, kill up to 165 million and trigger a global recession that could cost up to $3 billion would come in the next two generations. Currently, we’re living through three pandemics HIV, Zika and cholera. What will the next pandemic look like and where will it come from?

Those are some of the questions science journalist Sonia Shah attempted to answer in an event marking the centennial of the Johns Hopkins University’s Bloomberg School of Public Health and in her book “Pandemic: Tracking Contagions from Cholera to Ebola and Beyond,” published earlier this year. The book should be required reading for anyone interested in the future of global health.

Shah spent six years trying to figure out how microbes turn into pandemic-causing pathogens. She looked at the history of pandemics, particularly cholera because it’s one of our most efficient pandemic-causing pathogens. She went to places where new pathogens are emerging to try to figure out what are the political and social drivers that push these microbes into human populations.

She found that one of the major drivers is wildlife. A disproportionate number of human pathogens come from other primates, who’ve given us 20 percent of our most burdensome pathogens (including HIV and malaria).

“About 60% of the new pathogens are emerging in animals,” she said. “Over 70% of those come out of wild animals. From bats, we’ve gotten Ebola, Nipah, SARS and Marburg, from birds we’ve gotten Avian influenza and West Nile virus, from rodents we’ve gotten Monkey Pox and Lyme Disease, from monkeys we’ve gotten malaria and HIV and probably Zika.”

The expansion of the human population is destroying wildlife habitat and this results in the remaining wildlife crowding in ever closer to humans.

“We’re creating more and more interfaces between humans and wildlife that allows for novel, more intimate kinds of contact in which the microbes that live in their bodies, can spill over into our bodies,” she said.

And animals, as well as humans, are crowding together. Shah says we have more animals under domestication today than in the last 10,000 years of domestication until 1960 combined. And an increasing proportion of these animals are living on factory farms, which she calls “the animal equivalent of slums, where you have hundreds of thousands of animals crowded really closely together where they’re breathing on each other, touching each other and being exposed to each other’s wastes. This is another opportunity new pathogens are exploiting.”

This new sanitary crisis is in addition to our old sanitary crisis in which 2.6 billion people don’t have access to any modern sanitation. In this new crisis, livestock produces 7 billion tons of excreta every year, which is far more than our crop lands can absorb. So we have giant open cesspools of untreated animal waste, which seeps into the environment.

And we’re spreading these pathogens around more efficiently than ever with extensive flight networks. Consequently, Shah says, even when one of these pathogens emerges in a place where there’s not a lot of susceptible people, it can quickly travel to a place where there are, to such an extent that we can predict where a pathogen will strike next by measuring the flights between infected and uninfected cities.

Since a lot of these pathogens are coming out of animals and driven through human populations by social and political factors, you would think that the best way to tackle this problem would be through an interdisciplinary approach. “Get the veterinarians, wildlife biologists, ecologists, engineers, anthropologists, political scientists, economists and bio-medical specialists together to look at the entire process,” she said. “But of course, that’s not what we do. We approach infectious outbreaks as solely a bio-medical phenomenon, reducing it to its smallest components, and then striking it down with surgical precision.”

Shah pointed out that Brilliant didn’t have a crystal ball. He was merely a warning of what will happen if we don’t change. She believes there is a lot that we can do with early detection, as this article points out. We don’t have to wait for the vaccines and drugs.

Ultimately, she said, we have to reduce the conditions that allow pandemics to occur, things like restoring wild habitats, so the microbes in animals stay in animals and do not cross over into humans. We have to protect the health of the most vulnerable among us, people who live in slums and animals in factory farms.

“We need to reimagine our relationship to the microbial world,” she said. “There is no ‘us’ and ‘them’ anymore. This is their planet, and they were here first. And they’re a lot better at living here than we are. We have to recognize that our health is connected to the health of our societies but also the health of our animals, our wildlife and our ecosystems.”

So what will the next pandemic look like? Shah says we don’t have a great track record predicting pandemics (no one predicted Zika) but sees two scenarios as the most likely:

1) A novel form of influenza, because influenzas are so efficient at spreading that even a slight increase in mortality from a virus would result in a huge number of deaths; or

2) An antibiotic-resistant bacteria, which poses a huge threat to public health because even a common injury like a scratch can become life threatening.

Shah says there is one thing that lets her sleep. “Look at it from the pathogen’s point of view. They need to transmit from one person to another but if they kill you too fast, they’re not going to be able to transmit very well. That helps me sleep.”

Controversy Brewing Over The Greatest Barriers to Access to Medicines

16th Aug 2016

A worker selects medicine from MEDS (Mission for Essential Drugs and Supplies) warehouse in Nairobi. MEDS is jointly owned by the Kenya Conference of Catholic Bishops and the Christian Health Association of Kenya. Photo: Bedad Mwengi

A worker selects medicine from MEDS (Mission for Essential Drugs and Supplies) warehouse in Nairobi. MEDS is jointly owned by the Kenya Conference of Catholic Bishops and the Christian Health Association of Kenya. Photo: Bedad Mwengi

 

By David J. Olson

In comments last week at the International AIDS Conference in Durban, South Africa, UN Secretary-General Ban Ki-moon said four things deserved credit for getting the AIDS pandemic under control people living with HIV, biomedical companies, generic medicines and international finance.

But despite his gratitude to biomedical companies and generic medicines, the Secretary-General is overseeing a process that may threaten to undermine those companies’ ability to improve access to medicine in developing countries.

The World Health Organization says an estimated 2 billion people (27% of the world’s population of 7.5 billion) lack access to essential medicine, most of them in Africa and Asia, and a full three-quarters of the world’s population (around 5.5 billion) have no access to proper pain relief treatment.

To address this staggering problem, the Secretary-General set up a High-Level Panel on Access to Medicines earlier this year. The purpose of the panel was “to review and assess proposals and recommended solutions for remedying the policy incoherence between the justifiable rights of inventors, international human rights law, trade rules and public health in the context of health technologies.”

Sounds like a great and noble idea, right? But some expert commentators think the panel is on track to do more harm than good because of its terms of reference.

Secretary-General Ban Ki-moon told the panel to focus on intellectual property and the pharmaceutical companies’ protection of patents and ignore the other issues that hamper access to medicine weak health systems, questionable government policies and a lack of doctors, nurses and community health workers.

Reports like this one suggest that the panel not only attacks the patent system but proposes to put the United Nations in charge of drug development. The High-Level Panel has said that the leaks may not be accurate and that the panel is still actively working on the report. The High-Level Panel was contacted for comment but did not respond before this article was published. When it is released, the report will be published on the panel’s official website.

There are so many more issues that influence access to medicines than intellectual property and patents. Some would argue that patents are not an obstacle to health at all but a tool to promote health.

“Far from being a threat to public health, patents are indispensable to promoting life-saving medical research,” writes Joseph Allen, who consults on intellectual property and formerly headed the National Technology Transfer Center.” If companies couldn’t protect their inventions through intellectual property laws, they’d have little reason to take the enormous risks involved in drug discovery. It’s not a coincidence that drugs are only created in a few countries with strong patent systems.”

And Dr. Kristina Lybecker, an associate professor at Colorado College, writes that patents not only foster pharmaceutical innovation, but also inhibit counterfeiting and fake drugs, which are widely recognized as serious barriers to access to high-quality drugs.

In recent interviews conducted by Baird’s CMC Ltd. with nine high-level Kenya public health professionals, none of them mentioned intellectual property as a key barrier to access to medicines. The two most common responses were weak health systems and cost of medicines and doctor consultations. Other reasons included late diagnosis, sub-standard drugs and a lack of health-seeking behavior on the part of the patients.

“Many times, consultancy fees are more expensive than the medicines,” said Professor Isaac Kibwage of the College of Health Sciences, University of Nairobi. “It is a bigger barrier in access to medicine.”

Similarly, in Senegal, three public health officials interviewed did not identify intellectual property as as issue but all of them identified cost of doctor visits or user fees for diagnostics.

Of 16 people active on pharmaceutical issues interviewed by Fundamento RP, a Brazilian qualitative market research consultancy, only one of them (described as an AIDS activist) identified patents as a problem. Three of them specifically said patents were not the problem.

Taila Lemos, the founder of Gentros, the Campinas Start Up, the Beta Lounge consulting innovating and Corporate Garage has a long history in the pharmaceutical field in Brazil. She said that the panel should have had more industry participation — the two Brazilians on it are very qualified, but are both from government, and the panel needs people who have actually developed medicines in the private sector.

“Here in Brazil we have people who say they are experts in Amazonia forests but they have never set foot in the Amazon,” she says. “It’s the same thing with this panel.”

She said patents are the drivers of innovation. “We developed four vaccines for animal health. It took 10 years to bring them to market. If we don’t have the protection of intellectual property, no one will invest in the development of these drugs.”

Kenya Starts to Shift Focus To Chronic Diseases While Not Relenting in HIV Fight

28th Jun 2016

A patient at a rural health camp in Mwae County, Kenya has his blood pressure checked as part of a full physical exam. If he needs hypertension treatment, he will get it as part of the cost of the camp. Photo: Bedad Mwangi

 

By David J. Olson

For some time, huge disparities between global health spending and the global disease burden have raised concerns that this funding was not being allocated based on the evidence. That is, money was not always going where the disease burden was greatest.

The Institute for Health Metrics and Evaluation (IHME) has pointed out that the disparities are most extreme in HIV/AIDS on the high end and non-communicable diseases (NCDs) on the low end.

As the toll from communicable diseases like AIDS and malaria decline and people live long enough to get NCDs, we need to invest more in fighting NCDs (also called “chronic diseases”) and reduce these glaring disparities between global health spending and disease burden. Countries like Botswana, Eritrea, Kenya Malawi, Mozambique, Rwanda, South Africa, Swaziland, Tanzania, Uganda, Zambia and Zambia all countries that increased their treatment coverage by more than 25% between 2010 and 2015, according to UNAIDS now have to pivot to NCDs without taking their eyes off of HIV.

Kenya is an excellent case in point. Life expectancy there peaked in 1987, and then went down in the 1990s, as AIDS made its presence felt. But as more Kenyans have gotten AIDS treatment and new infections declined, life expectancy started going up again, and is expected to return to its historic peak of 60 years in 2017, according to a World Bank blog.

That’s great news but that silver lining contains some bad news: Some people are now living long enough to get an NCD like cardiovascular and respiratory disease, diabetes and cancer.

Annually, 28 million people die from NCDs in low- and middle-income countries, representing nearly 75% of deaths from NCDs globally. Health programs, therefore, must turn their attention to this new pandemic without losing focus on the existing AIDS pandemic. And donors and governments must follow suit with funding that is in synch with the disease burden and not based on 1990s realities.

Dr. Samuel Mwenda is a seasoned soldier against both pandemics. For 13 years, as the general secretary and CEO of the Christian Health Association of Kenya, a network of Protestant church facilities in Kenya, he has led CHAK’s approach to HIV/AIDS prevention, care and treatment.

CHAK has made significant contributions to the national fight against AIDS in the four most populous provinces of the country and now supports over 41,000 clients with antiretroviral therapy, representing about 9% of the total number of patients nationally. Kenya now has the second largest treatment program in Africa (after South Africa), with nearly 900,000 people on treatment at the end of 2015.

CHAK has helped Kenya become an AIDS success story. UNAIDS says that Kenya is one of the countries “showing the most remarkable progress in expanding access to antiretroviral medicines and reducing the number of new infections.”

Several years ago, CHAK turned its attention to the emerging pandemic of NCDs, and began working on hypertension and diabetes. Seventy percent of the global cancer burden is in low- and middle-income countries like Kenya, where the probability of dying between the ages of 30 and 70 from one of the four main NCDs is 18%. NCDs account for 27% of deaths in Kenya, according to the World Health Organization.

In 2015, with the support of Novartis Access, CHAK started offering a portfolio of products to treat diabetes, hypertension, asthma and breast cancer at an end price not to exceed $1.50 per treatment per month. The program is currently in three counties of Kenya and is expected to be in all 47 counties by the end of 2017, and followed soon by Ethiopia, Rwanda and Senegal. The program hopes to be in 30 countries by 2020, depending on government and stakeholder demand.

Novartis Access calls its program a “social business,” which it expects to eventually create value, not only for society but also for Novartis.

“A key learning from HIV programs was that you cannot build awareness until there is treatment,” said Mwenda. “It’s the same with NCDs. It’s access to treatment that gets individuals and families to learn about heart disease and diabetes and to come forward for diagnosis. When people see others in their communities living long, healthy and productive lives despite NCDs, it makes them more willing to invest their own time and resources in treatment.”

“Africa is rapidly overcoming the challenges of infectious diseases,” said Mwenda. “Much of that is due to the commitment of faith-based organizations, that  provide about half of all health care in the countries south of the Sahara. I believe that the same God-given mandate that we had to conquer polio and AIDS requires us to get serious about diabetes and cancer.”

On June 19, Mwenda became the third recipient of the Christian International Health Champion Award, which honors an individual who has dedicated his/her life to global health from a Christian perspective and has made significant contributions to the field and to Christian Connections for International Health (CCIH), which presented him with the award. Full disclosure: David J. Olson is a board member of CCIH.

Millions Saved Shows That Global Health Programs Can Achieve Success

24th May 2016

A child receives a MenAfriVac Meningitis A vaccination in Burkina Faso, the first country to roll out the vaccine in 2010. By the end of 2013, more than 135 million people had been vaccinated with MenAfriVac in 12 countries. The MenAfriVac vaccination campaign is one of the success stories described in "Millions Saved." Credit: PATH

A child receives a MenAfriVac Meningitis A vaccination in Burkina Faso, the first country to roll out the vaccine in 2010. By the end of 2013, more than 135 million people had been vaccinated with MenAfriVac in 12 countries. The MenAfriVac vaccination campaign is one of the success stories described in “Millions Saved.” Credit: PATH

By David J. Olson

If you are reading this article, you probably already believe in global health, and its ability to improve the quality of life and save lives. Every month we tell some of these stories here at Global Health TV.

But some people do not believe that global health programs work or, perhaps, are just indifferent to that fact. The Kaiser Family Foundation recently released a survey of the U.S. general public that showed that the visibility of U.S. global health effort are declining – only 36% have heard a lot or some about U.S. efforts in the past year, down from 57% in 2010.

That’s why books like “Millions Saved: New Cases of Proven Success in Global Health,” written by Amanda Glassman, Miriam Temin and a team at the Center for Global Development, are so important. They provide us with specific examples of global health success that they culled from more than 300 examples of rigorous impact evaluations, and explain why they were successful.

“Around the world, people are benefiting from a global health revolution,” wrote Glassman and Rachel Silverman, both of the CGD, in a blog of the British Medical Journal (BMJ). “More infants are surviving their first months of life; more children are growing and thriving; and more adults are living longer and healthier lives. This amazing worldwide transformation begs several questions: What, specifically, are we doing right? What are the policies and programs driving the global health revolution from the ground up? Or put more simply, what works in global health, and how do we know?”

Those are the questions the authors set out to answer in this, the third version of “Millions Saved.” The first, published in 2004, provided 17 large scale global health successes. In 2007, the second edition updated the original 17 cases, and added three new ones. The 2016 version profiles 22 cases – 18 success stories and four cases of promising interventions that could not maintain success when scaled up. No one likes to talk about their failures and disappointments, but much can be learned from them.

The authors have provided us with an amazing variety of health interventions ranging from disease-specific areas like HIV, malaria, meningitis, diarrhea, polio and cancer to broader programs like neonatal, child, maternal and family health, and cash transfers, pay-for-performance and universal health care. As well as tobacco control and road safety. Africa and Asia each had seven case studies and four came from Latin America and the Caribbean.

I was disappointed that the authors could not find any successes in family planning, as the first two editions had. They addressed this in the BMJ blog:

“We are often asked about why the new Millions Saved omits a favored intervention, disease priority, or specialty. Where is mental health, for example? Or heart disease? Cancer? And what about tuberculosis or family planning? The answer is always the same: despite our best efforts, we could not find a suitable, rigorous evaluation of an at-scale program that demonstrated attributable health impact. That is not to say that interventions in these areas have not improved health at scale – it is quite likely that they have. But without rigorous at-scale evaluation, we simply cannot and do not know for sure.”

Dr. Duff Gillespie, professor at the Bill & Melinda Gates Institute for Population and Reproductive Health at the Johns Hopkins Bloomberg School of Public Health, agrees there have been few well controlled intervention studies that measure the impact of family planning and suspects this will not change because donors do not see the need for such studies and because most researchers do not find such studies necessary.

“Why? There is a wealth of evidence documenting the use-effectiveness of contraceptives in preventing pregnancies. There is also tons of evidence that shows contraceptive use increases with access to family planning services. Lastly, the correlation between contraceptive use and reductions in maternal and child mortality is one of the strongest in public health. Are such correlations causal? In the case of reductions in the maternal mortality rate, absolutely. Since women must be pregnant to become a maternal death, any intervention that is effective in reducing the number of pregnancies will result in a reducing of maternal deaths. This is where contraceptive use has its biggest impact.”

Kim Longfield, director of Strategic Research and Evaluation at Population Services International (PSI), says her team did a systematic review of the effectiveness of social marketing in family planning and found a study of one program that was at scale and had significant impact – “A randomized community trial of enhanced family planning outreach in Rakai, Uganda,” which was published in Studies in Family Planning in March 2010.

The prevalence of pregnancy decreased by 3.1% in the intervention group (from 16.6% to 13.5%) and 1.3% in the control group (from 18.1% to 16.8%) between baseline and follow-up three years later. Longfield said this difference was “statistically significant.”

Longfield also said that rigorous evaluations of at-scale programs are “incredibly difficult to carry out on programs at scale. Imagine trying to have control groups at a national level.”

Steven Chapman, evidence, measurement and evaluation director of the Children’s Investment Fund Foundation in London, says that there is already ample evidence of family planning causing a decline in fertility, child mortality and maternal morbidity and mortality without trying to prove it as rigorously as is required by the “Millions Saved” case studies.

“Amanda encourages us to do a rigorous study to prove the connection but I think it is unnecessary – the health benefits of family planning are one of the many quantifiable benefits of it, and we can’t count the non-quantifiable ones.”

I hope to see this series continue into the future, perhaps with a family planning success the next time. Indeed, Glassman and Silverman end their BMJ blog with a plea: “If you care about cancer or heart disease, or tuberculosis, or family planning, please help us include it in the next “Millions Saved.”

Summaries of the twelve of the 18 success stories documented in “Millions Saved” can be found here, on the CGD website. A hard copy of the book can be ordered here.

Lesson_MillionsSaved_0516BlogLg

In West Africa, More People Using Family Planning but Millions Not Treated for HIV

26th Apr 2016

National Family Planning Campaign

People gather for the Bamako launch of the national family planning campaign in Mali earlier this month. Only 9.9% of married women use modern contraception, according to the 2012-2013 Demographic and Health Survey. Photo: David J. Olson

By David J. Olson

BAMAKO, Mali Last year, there were several reports of how West Africa, after decades of seriously lagging behind the rest of the world (and Africa) in family planning, was finally starting to embrace it. IntraHealth International covered this topic extensively on its Vital blog, and I wrote about my own views of family planning in Mali here at Global Health TV.

Senegal, in particular, emerged as a family planning leader in West Africa and provided hope for the rest of the region. The three main reasons for Senegal’s success were strong political will, better coordination and collaboration and innovative approaches, according to Babacar Gueye, IntraHealth country director in Senegal.

New programs here in Mali, like Keneya Jemu Kan (USAID Communications et Promotion de la Santé, in the Bambara language), are making a major push to increase health indicators beyond the anemic progress of the past three decades. For example, the percentage of married women using any modern method of family planning in Mali has only increased from 1.3% in 1987 to 9.9% in 2013, and Keneya Jemu Kan is working to bend that rate upwards. (Full disclosure: I work as a consultant for Keneya Jemu Kan).

But a disturbing new report from Médecins Sans Frontières (MSF), or Doctors Without Borders, claims that similar progress is not being made in HIV/AIDS. On the contrary, MSF claims that millions of people in West and Central Africa are being left out of the global HIV response despite globally agreed goals to curb HIV by 2020, and is calling on the international community to develop and implement an urgent plan to scale up antiretroviral treatment for countries where critical medicines reach fewer than one-third of the population in need.

The 25 countries that make up West and Central Africa account for one in five new HIV infections globally, one in four AIDS-related deaths and nearly half of all children born with HIV. MSF points out that the region has a low HIV prevalence, with 2.3% of the population infected with HIV, but that is three times the worldwide prevalence of 0.8%, and pockets of the region have prevalence over 5%.

HIV prevalence in West and Central Africa is lower than Eastern and Southern Africa. This lower prevalence has led to “poor knowledge of the disease among the general population, political leaders and health workers” and less funding by international donors.

“The converging trend of international agencies to focus on high-burden countries and HIV hotspots in sub-Saharan Africa risks overlooking the importance of closing the treatment gap in regions with low antiretroviral coverage, said Dr. Eric Goemaere, MSF’s HIV referent. “The continuous neglect of the region is a tragic, strategic mistake. Leaving the virus unchecked to do its deadly work in West and Central Africa jeopardizes the goal of curbing HIV/AIDS worldwide.”

Pape Gaye, president and CEO of IntraHealth and a native of Senegal, says that the problems cited by MSF are another example of why the international community needs to mobilize to help countries strengthen their health systems.

“The difficulties experienced by Ebola-affected countries to address the disease and the inabilities of countries to protect and sustain gains, including recent ones in family planning and reproductive health, point to the need for more attention to health systems strengthening,” said Gaye. “The region of West and Central Africa is poised to enter a new era of growth and prosperity but the momentum will dramatically slow down or vanish unless coordinated effort is made to rid the region of HIV/AIDS. This is not the time to continue erratic and fragmented interventions which produce results such as those described in the MSF report.”

The Ouagadougou Partnership, an initiative of nine French-speaking West African countries to promote family planning started in 2011, set a goal of reaching one million new family planning users in these nine historically under-performing countries by 2015. At their annual meeting in December 2015, members of the Partnership celebrated the achievement of this goal.

MSF is now calling for the same kind of urgent call to arms to address HIV/AIDS and a plan to achieve progress, much as the Ouagadougou Partnership did to address family planning. If we can do it for family planning, we should be able to do it for HIV/AIDS and thereby ensure that West and Central Africa do not thwart our efforts to achieve an AIDS-free generation.

Diarrhea Deaths Are Falling But ORS Use Still Stagnant

26th Oct 2015

By David J. Olson

I’m grateful to Chelsea Clinton for her admission that she is “obsessed with diarrhea,” and her total lack of embarrassment in bringing it up repeatedly. In an interview with Fast Company, it was the first thing she wanted to talk about.

I’m grateful to her because she is, as far, as I know, the only well-known public figure to champion the prevention and treatment of diarrhea, the world’s second biggest killer of children under five years old, even though we have cheap and effective ways of dealing with it.

“It’s completely unacceptable that more than 750,000 children die every year because of severe dehydration due to diarrhea,” said Clinton last year. “I just think that’s unconscionable.”

We need more champions of the diarrhea issue.

Four years ago, I wrote a blog bemoaning the fact that oral rehydration therapy (ORT) seemed to be on life support, even though The Lancet once called it “the most important medical advance of the 20th century.” ORT and its practical application, oral rehydration solution (ORS), have long been found to be both effective and cost-effective in treating the dehydration caused by diarrhea.

Bangladesh is perhaps the best example of a country that has made stellar progress in fighting diarrhea through ORS. The treatment of diarrhea increased from 58% in 1993 to 81% in 2011.  Productive collaborations between the government, the private sector and organizations like the Social Marketing Company, which used social marketing revenues to build an ORS factory in Bangladesh in 2004, have led to tremendous improvements in diarrhea disease management.

Starting in the 1970s, ORS has saved an estimated 50 million lives, costing less than $0.30 per sachet, according to the WHO. In 1978, the World Health Organization (WHO) established the Control of Diarrheal Diseases Program, and by the early 1980s, most developing countries had their own dedicated national programs.

But even though ORS was cheap and effective, the global health community moved on to other diseases, like AIDS and malaria. In the 1990s, these diarrheal disease programs were merged into broader child health programming, and lost their dedicated funding, staff, and systems. A 2008 analysis that looked at changes in ORS use in children under three found declines in 23 countries and increases in only 11.

A 2009 research study conducted by PATH, a leading NGO working to fight diarrhea, to evaluate the funding and policy landscape found that “diarrheal disease ranked last among a list of other global health issues.”

After years of neglect, diarrhea is back on the global health map. Diarrhea deaths among children under five are down from 700,000 per year in 2011 to around 531,000 in 2015, according to PATH, a drop of 24% in four years. The bad news is that ORS use has stagnated, says PATH, at around 35% over the last 10-15 years.

Why has diarrhea death dropped even though ORS has stagnated?

“It’s been because of increasing access to a set of protection, prevention and treatment interventions,” said Ashley Latimer, senior policy and advocacy officer at PATH. “More children are being vaccinated against rotavirus (a leading cause of diarrhea). Understanding the importance of hand-washing and clean drinking water is improving. Improved nutrition and exclusive breastfeeding probably plays a small role.”

In 2013, the WHO and UNICEF published “Ending Preventable Child Deaths from Pneumonia and Diarrhoea by 2025,” the first-ever global plan to tackle the two diseases that take the lives of 2 million children every year, which was supported by more than 100 nongovernmental organizations.

There are several efforts underway to fight diarrhea more effectively.

For example, PATH is working to improve the formulation of ORS to make its benefits more apparent to caregivers.

Rehydration salts for Diarrhea

A mother administered oral rehydration salts to her child in Kenya. Credit: PATH/Tony Karumba

“Reimagining global health” recently highlighted “30 high-impact innovations to save lives.” One of them (see Page 17) included several new treatments to reduce the burden of severe diarrhea, such as DiaResQ, which supplements the use of ORS and provides nutrients for intestinal repair.

An already established innovation is to create “comprehensive diarrhea treatment” by combining zinc with ORS. Zinc is a vital micronutrient that helps the body absorb water and electrolytes, reduces the duration and severity of diarrhea and prevents subsequent infections in the two to three months following treatment. Diarrhea mortality is reduced by 23% when zinc is administered with ORS. Unfortunately, use of zinc is even worse than ORS – only 5% as compared to 35% for ORS.

Diarrheal disease research and development funding is increasing modestly. In 2013, it was $200 million, up from $170 million in 2012. As in previous years, the top three funders accounted for almost three-quarters of total funding – the Bill & Melinda Gates Foundation (25% of funding), the U.S. National Institutes of Health (23%) and industry (22%).

“With the introduction of rotavirus vaccines and advances in WASH interventions, these are exciting times,” said Deborah Kidd, senior communications officer at PATH. “However, what is often overlooked is the burden of diarrhea morbidity among children in the developing world. Chronic, repeated infections, resulting malnutrition and stunted development, and the persistent economic burden on the family all contribute to a destructive cycle that keeps families in poverty. So it’s great news that deaths are declining, but that the problem of childhood diarrhea and its long-term consequences are far from solved.”

UNICEF reports that improvements in drinking water, sanitation and hygiene are reducing diarrheal disease (90% of the world’s population use improved drinking water sources and two-thirds use improve sanitation facilities).

However, the decline in diarrhea deaths should be no cause for complacency: UNICEF also reports that when children do fall ill with diarrhea, only two in five children receive appropriate treatment, including ORS.

Unlike many diseases, for which no cure exists, the cure for diarrhea has been around for decades and is cheap and available. We just have to find the financial, technical and social means to get it to people who need it, and help them use it to protect the health of their families.

This infographic shows the status of the war against pneumonia and diarrhea in the world’s poorest children.

 

Budget Debates in US, UK Could Augur Poorly for Global Health Funding

25th Jul 2017

 

mother-holding-her-babyblog

By David J. Olson

Global health financing has not been in such jeopardy since the large investments in it started in 1991 – the year in which global health funding started an upward trajectory that moved higher in all but three years.

In particular, the rise of Donald Trump of the United States and Theresa May of the United Kingdom the leaders of the two largest donor nations have raised concerns about the prospects for development assistance broadly, and global health specifically.

In 2016, development assistance for health (DAH) reached $37.6 billion, eking out a miniscule 0.1% increase from 2015 that followed a pattern of little growth since 2010 (DAH grew 11.4% annually from 2000 to 2010 but only 1.8% since 2010), according to “Financing Global Health 2016,” published by the Institute for Health Metrics and Evaluation in April. DAH peaked at $38 billion in 2013, dropped to $36 billion in 2014 and has recovered slightly in the two subsequent years. This infographic provides a snapshot.

 

The U.S. and the U.K. have been the two top contributors to DAH but both countries have political environments that have called into question their future commitments to foreign aid and global health.

 

Trump’s 2018 budget request to Congress contains unprecedented cuts (more than $2 billion) to global health. If those cuts are enacted, writes the Kaiser Family Foundation, they will bring funding below 2008 levels. Family planning support would be eliminated. Kaiser predicts the cuts could result in the following scenarios starting in 2018:

 

  • Additional new HIV infections between 49,100 to 198,700;
  • Women and couples receiving contraceptives would decline from 6.5 million to almost 25 million; and
  • Additional abortions between 819,000 and more than 3 million.

 

More than half of the $2 billion in cuts to global health would come from international HIV/AIDS programs. In a new paper, the Center for Strategic and International Studies says the cuts would jeopardize U.S. leadership on HIV/AIDS and “raise the possibility that the pandemic will reignite, threatening U.S. and global health security.”

 

However, in the U.S. political system, Congress has the last word on the budget, and even Republican senators say these cuts will not stand. But however the final budget turns out, it could still perpetuate the recent stagnation in global health financing.

 

A series of hearings earlier this month featuring Secretary of State Rex Tillerson and U.S. Agency for International Development Administrator-designate Mark Green revealed how the Trump Administration is of two minds about foreign aid.

 

Tillerson testified at four hearings on the proposed budget cuts. Republicans and Democrats alike lambasted the proposed cuts. Sen. Lindsay Graham, the Republican chairman of the Senate subcommittee that oversees foreign aid, said these cuts would put lives at risk. Tillerson defended the cuts, saying “Our budget will never determine our ability to be effective. Our people will.”

 

Good news came with the nomination of former Ambassador and Congressman Mark Green to lead USAID. Green was well received by both political parties in his testimony before the Senate Foreign Relations Committee on June 15, and he talked with pride about the work of USAID (we also learned that his parents were born South African and British).

 

For global health advocates, one of the most worrisome aspects of Trump Administration policy has been the reinstatement and expansion of the Mexico City Policy. This policy requires foreign non-governmental organizations to certify that they will not “perform or actively promote abortion as a method of family planning” using funds from any source as a condition for receiving U.S. family planning assistance.

 

Green tried to calm concerns about the policy. “The State Department is undertaking an intensive six-month review to study the impacts of the expanded policy and whether it leads to interruption of services on the ground,” said Green in his testimony. “USAID will be part of that and we will play it straight. You can count on us to be honest brokers in that process.”

 

In the U.K., meanwhile, a different scenario has been playing out. In 2013, the UK became the fifth country to reach the UN goal of dedicating 0.7% of its gross national income to foreign aid, driven in large part by former Prime Minister David Cameron. But after the Brexit upset in 2016, Theresa May became prime minister and appointed conservative Member of Parliament Priti Patel as her international development secretary.

 

At the time, Patel roundly criticized British aid as being a waste of money and promised a major overhaul of the aid budget, according to the Daily Mail.

 

“My approach will be built on some core conservative principles that the way to end poverty is wealth creation, not aid dependency; that wealth is ultimately created by people, not by the state; that poor countries need more investment and trade, not less,” she was quoted in The Guardian. “And we need to empower the poorest to work and trade their way out of poverty, not treat them as passive recipients of our support.”

 

In March 2017, a cross-party parliamentary committee on international development concluded that “ODA [official development assistance] spending is in the national interest and is a strong investment contributing to create a more prosperous world, which pays far-reaching dividends including to UK taxpayers at home.” The committee did not find evidence of wasteful spending. In fact, they found the spending to be effective.

 

Recently, Patel has struck a more positive tone about ODA. She announced a new aid package for east Africa, boasted about the scale of UK development assistance and, when asked about the future of UK aid, said: “It’s never been so needed. We face more global challenges in 2017 than every before.”

 

We don’t know if global health funding will go up or down but one thing is clear: Green and Patel are both interested in finding approaches to foreign aid that go beyond treating people as passive recipients of cash and that spark more economic investment and trade. It will be interesting to see what that means for global health.

 

 

Health Workers, Facilities Under Attack in 23 Nations; UN Accused of Inaction

23rd May 2017

This hospital was damaged by clashes during a 79-day curfew from late 2015 to early 2016 in the city of Cizre in southeastern Turkey. Photo: Physicians for Human Rights

This hospital was damaged by clashes during a 79-day curfew from late 2015 to early 2016 in the city of Cizre in southeastern Turkey. Photo: Physicians for Human Rights

By David J. Olson

In 2012, two Pakistani health workers were out vaccinating children against polio when they were both shot by extremists. One of them died. The other, shot in the leg, had 11 metal rods inserted into his leg and was hospitalized for three months.

In November, I met this remarkable man named Latif (his surname is withheld to protect his security). He is now fully recovered and back to work on the polio vaccination campaign. He told me he never considered giving up. Pakistan reported only two cases of wild poliovirus in 2017 as of May 17 and Latif is determined to see the polio campaign through to the end.

The attack on Latif is only one example of a tragic phenomenon that is not getting better – violence against heath workers and health facilities. In 2016, the extent and intensity of such violence “remained alarmingly high,” according to a new report released by the Safeguarding Health in Conflict Coalition.” The report also found that accountability for committing these attacks remains inadequate or non-existent.

The violence isn’t always perpetrated by terrorists. Sometimes it is committed by the police or the country’s military institutions that should be ensuring tranquility.

Most of us have heard of hospitals and clinics getting blown up or polio vaccinators getting shot but the report indicates that attacks on health care take many forms. It names eight different forms of violence:

      •  Bombing and shelling of health facilities (reported in 10 countries in 2016)
      •  Looting of health facilities (11)
      •  Killing of health workers, emergency medical personnel and patients (11)
      •  Intimidation, assault and arrest of health workers and patients (20)
      •  Abduction of health workers (11)
      •  Obstruction of access to care including blockage of and attacks on ambulances (10)
      •  Takeover and occupation of health facilities by police, military or other armed actors (7)
      •  Attacks on and blockage of humanitarian actors, supplies and transports (15)

 

The report documents attacks on health care in 23 countries in 2016. Most of the countries are in Africa and the Middle East but there are a few exceptions (Armenia, India, Myanmar and Ukraine). The report was released on May 3, the first anniversary of the UN Security Council’s adoption of Resolution 2286 that set out a roadmap to the protection of health workers in conflict.

The Safeguarding Health in Conflict Coalition says the UN Security Council has failed to follow through on its own recommendations for preventing attacks and providing accountability for those who commit them. These recommendations include regular reporting to the UN on actions taken to prevent attacks, to investigate attacks, and to hold perpetrators accountable. The U.N. Press Office did not respond to my request for a comment.

“Our findings cry out for a level of commitment and follow-through by the international community and individual governments that has been absent since the passage of Security Council Resolution 2286 a year ago,” said Leonard S. Rubenstein, chair of the coalition and director of the Program on Human Rights, Health and Conflict at Johns Hopkins University Bloomberg School of Public Health in a press release issued on the anniversary.

The International Committee of the Red Cross, which has had a campaign called Health Care in Danger since 2011, says the attacks have increased despite the commitments. The slogan of the campaign is “Everyone wounded or sick has the right to health care.”

In Pakistan, doctors supervising the polio vaccine campaigns and police protecting community health workers were shot and often killed in a number of attacks. Many of these attacks took place in areas where wild polio virus is endemic. In August, a suicide attack at Quetta Civil Hospital in Quetta left 74 civilians dead and up to 112 wounded. Though it targeted a group of lawyers and journalists who were mourning a colleague, this bombing was one of the deadliest attacks on a medical facility in the history of the region, according to the report.

In Mali, Human Rights Watch reported that on at least six occasions, ambulances and other vehicles used to transport patients and deliver health care were attacked or robbed. In four of these incidents, sick passengers, drivers and health workers were forced out of the vehicles and robbed and the vehicles stolen. In another incident, an improvised explosive device struck an ambulance that was headed to the scene of another IED attack that killed two peacekeepers.

Syria was the worse country in terms of intensity and impact of the attacks. Physicians for Human Rights reported 108 attacks on health facilities in 2016, most by the country’s own military and Russian forces, and the death of at least 91 health workers.

These are just a few examples of the many tragic incidents in 23 countries detailed in the report.

It is clear that these attacks can have profound effects on the availability of health care. They result in:

Suspension of health programs

        • Degradation of the health infrastructure
        • Exodus of health workers concerned about their security
        • Outbreaks of disease and illness and inability to treat existing conditions

 

Accountability for such reports is largely absent, according to the report. A review by Human Rights Watch of 25 major incidents of attacks on health care between 2013 and 2016 found that either no investigations at all were pursued, or the investigations were inadequate.

As bad as the situation is, the numbers noted in the report may only be the tip of the iceberg because there are surely many attacks that go unreported. And the danger goes beyond the health workers who bear the initial brunt of the attacks.

“Although attacks on health workers are obviously dangerous for the workers themselves, they are also a danger to the communities they serve,” said Laura Hoemeke, director of communications and advocacy at IntraHealth International, one of the key members of the coalition. “If they do survive the attacks, many flee their communities and countries, leaving behind people with even less access to health care. This limited access has a particularly negative impact on maternal, newborn and child health.”

It is bad enough that anyone, anywhere has to do without health care. But to deny healthcare to those living in a state of war or unrest is unconscionable. As The Lancet commented, “One attack on a health worker is one too many.”

Promoting Contraceptives To Adolescents in Mexico? Make the Campaigns Fun

21st Mar 2017

Monserrat, Ariatne and Isis and their children visit a RED DKT clinic in the Iztapalapa borough of Mexico City to find a contraceptive to space the birth of their next child. Photo: David J. Olson

Monserrat, Ariatne and Isis and their children visit a RED DKT clinic in the Iztapalapa borough of Mexico City to find a contraceptive to space the birth of their next child. Photo: David J. Olson

By David J. Olson

MEXICO CITY, Mexico I met the three young women at a reproductive health clinic in Iztapalapa, the most populous and fastest-growing borough of Mexico City, with a population of 1.8 million on the eastern side of the capital city.

Ariatne and Isis, both 20 years old, each have one child. Monserrat was their aunt, but didn’t look much older. She had three children. All of them were looking for a way to space the birth of their next child. One of them wanted to wait five years; another, ten years.

All of them had chosen intrauterine devices (IUDs) as their contraceptive, one of them told me, “because they are comfortable and secure.”

Although unplanned pregnancy is a big problem in Mexico (and the rest of Latin America), good sexual and reproductive healthcare is hard to come by in Mexico, especially for adolescents, according to a recent study.

Almost three-quarters of pregnancies among adolescents aged 15-19 in the region are unplanned, according to the Guttmacher Institute, and about half of those end in abortion. Among all women 15-19 who need contraceptives, 36% of them are not using a modern method. The unmet need is highest in Central America, where 46% of sexually active adolescents who want to avoid pregnancy are not using modern contraceptives.

DKT México, a non-governmental organization that uses social marketing to prevent HIV and promote contraception in Latin America and the Caribbean, has learned some lessons about how to promote contraception to young people after success in promoting condom use but failing to do the same with contraceptives after they took a more traditional approach.

In 2015, DKT México launched a family planning campaign focused on increasing awareness of pregnancy among teenagers and young adults. They opted for a serious, medical campaign in traditional pharmaceutical company style they talked in the negative and expounded on the myths of various contraceptive methods.

The campaign failed. Few young people attended their events or engaged their digital media. Their messages did not resonate with the audience they were trying to reach. This translated into poor contraceptive sales.

At the same time, they were having a highly successful Prudence condom campaign with well attended events a Facebook page with 2 million followers and a Twitter account with 47,500 followers. Their condom sales tripled between 2012 and 2016.

The contrast between the two campaigns strongly suggested that they had to apply the same fun strategy of openly talking about sex in their family planning work as they were doing in their condom work. So they made major changes to their campaign:

    •They avoided talking in the negative and focusing on myths. Instead, they focused on the positive results of contraception.

    •They realized that most Mexicans think of babies as a blessing from God, and it doesn’t help to talk of “unwanted” pregnancies, so they changed to “unplanned pregnancy.”

    •They shifted the focus to how these unplanned pregnancies can interrupt education, travel and careers, things about which young people care very much.

    •They stopped using the term “family planning” and started talking about “life planning.” Young people do not think in terms of family planning; they are more interested in planning their education, careers and other life goals. This is true not only in Mexico but in other countries as well, something I wrote about here.

“In short, we stopped being preachy and started being fun, adopting the same entertaining messages and approaches we were using to market Prudence condoms at schools, concerts and fairs,” said Karina de la Vega Millor, director general of DKT México. “The main message became ‘Have sex, have fun, but use double protection against a sexually-transmitted disease or an unplanned pregnancy that will change the course of your life.’”

DKT México created “Planficame Esta” (“Plan me this”), a lively digital platform with a website, and a presence on Facebook, Instagram and YouTube.

“These tools give fun messages about the importance of having a life plan and avoiding pregnancy until you are ready, said Millor. “There are plenty of ribald jokes, frank discussions and flirty talk full of double entendres to engage our audiences. Our Facebook page now has more than 1.1 million followers, and more engagement than any Facebook page dedicated to contraception in all of Latin America.”

The clinic I visited in Iztapalapa, where a majority of the residents are poor to middle class, is affiliated with RED DKT (DKT Network) which DKT started in Mexico a year ago to improve sexual and reproductive health and encourage use of long-acting reversible contraceptives like IUDs.

The bottom line is that DKT México learned from the mistakes of its first campaign. This new campaign promotes life planning, not family planning. It has resulted in more young people viewing DKT websites and social media platforms, sharing information with their friends and coming to DKT events and clinics to get information and products to help plan their lives.

And more of them are actually using contraception to avoid unplanned pregnancy. Millor says that DKT México has increased almost eight-fold its number of couple years of protection (the amount of contraception to protect a couple for one year) between 2012 and 2016. She said they estimate they contributed about 4% of all the couple years of protection in Mexico in 2016, according to DKT calculations. That may not sound like a lot until you realize that Mexico is the tenth most populous country in the world, with a population of 129 million.

DKT México is now expanding into Central America, the Caribbean and northern South America and it will apply the lessons it has learned in Mexico to these new countries.

Though Preventable, Cervical Cancer Causes Half Million Cases Per Year

28th Feb 2017

Four volunteers of ICANSERVE Foundation exhort women to take advantage of free cervical and breast cancer screening at an event in the Philippines. Photo: ICANSERVE Foundation.

By David J. Olson

Over 16 years ago, Sally Kwenda survived colon cancer and HIV, and then lost her husband and two children to AIDS-related illnesses.

“Just when I thought I was done with the hurt and the pain, I was diagnosed with stage II cervical cancer,” she recalls. “Many of those I have met on this journey have either passed away or are worse off than me. Many of them got their diagnoses when it was too late to change the tide. Yet cancer does not have to be a death sentence. My experience reveals that cancer is curable.”

Cervical cancer is the most common cancer among women in Sally’s home country of Kenya as well as in 38 low- and middle-income countries, mainly in sub-Saharan Africa, according to the American Cancer Society (ACS).

The reasons for the high rates of cervical cancer in Kenya, according to Deborah Olwal-Modi, executive director of the Kenya Cancer Association, include lack of knowledge and awareness, inadequate facilities for prevention and treatment, economic barriers, and co-morbidity of cervical cancer and HIV/AIDS. For example, almost all women (97 percent) do not know that a virus causes cervical cancer, according to a new study among women in major Kenyan cities.

Worldwide, there were an estimated 528,000 new cases and 266,000 deaths from cervical cancer in 2012, with more than 86% of those deaths occurring in less developed countries. Last year in India, it killed almost 70,000 women. And the situation is getting worse: The number of deaths is projected to rise to 443,000 annually by 2030, according to the World Health Organization (WHO).

And yet vaccination, early screening and treatment of precancerous lesions can prevent most cases of cervical cancer. In fact, ACS says cervical cancer is one of the most treatable cancers. In the U.S., for example, the cervical cancer death rate has declined by more than 50 percent over the last 30 years.

“HPV vaccination given to adolescent girls and inexpensive screening techniques replacing the too expensive, too complicated Pap smear could bring cervical cancer under control within a generation,” said Sally Cowal, senior vice president of global health at ACS.

Virtually all cases of cervical cancer are caused by the Human Papillomavirus (HPV) infection through sexual contact, and the optimal time for acquiring infection is shortly after becoming sexually active. That is why the WHO recommends vaccinations for girls aged 9-13 which WHO says is the most cost-effective measure against cervical cancer

Yet some parents seem to have a problem taking their young daughters in for a vaccination against HPV to protect them against infections which may seem far in the future and which is transmitted sexually. In the U.S., a 2014 study published by the U.S. Centers for Disease Control and Prevention showed that only 39.7 percent of girls aged 13-17 had received the full three doses of the HPV vaccine, much lower than the 87.6 percent of boys and girls of the same age that received tenanus-diptheria-acellular pertussis vaccinations.

In a report launched in conjunction with World Cancer Day on Feb. 4, the WHO said that the early diagnosis of cancer and prompt treatment, especially for breast, cervical and colorectal cancers, would lead to more people surviving the disease and cutting treatment costs. “Not only is the cost of treatment much less in cancer’s early stages, but people can continue to work and support their families if they can access effective treatment in time,” said the report.

How much would it cost to implement HPV vaccination in developing countries? Based on a study supported by ACS, Harvard T.H. Chan School of Public Health experts have estimated that approximately 60 million girls in 17 high-burden, low-income countries could be immunized over five years at a cost of approximately $800 million or $13.40 per fully immunized girl. If the U.S. government committed to funding 20% of that, it would equate to about $160 million, or $32 million per year.

But current funding is not well aligned with the actual burden of disease in countries where the U.S. governments supports health programs. “While more than a quarter of deaths in priority low- and middle-income countries is from chronic diseases, such as cancer,” says the ACS, “virtually no funding is provided to prevent those deaths.”

World Cancer Day was Feb. 4 and the theme was “We can. I can” and explores how everyone can do their part to reduce the global burden of cancer.

Certainly Sally Kwenda is playing her part. She is now a Relay for Life “Hero of Hope” (Relay for Life is an annual athletic event to raise funds and awareness for cancer education) with the Kenya Cancer Association and spends her time connecting with other cancer survivors and using the knowledge she has acquired to empower and encourage them.

“The best warrior is not the one who always wins the battle but the one who is not afraid to go back to the battlefield. My plea to every single person is: Now is the time to act. It is time to beat this disease. I strongly believe this is possible.”

The Lancet has just published a special issue on breast and cervical cancer on Feb. 25, 2017.

Cervical Cancer Fact Sheet

Cervical Cancer Fact Sheet

As Infectious Disease Falls, Chronic Disease Increases; Possible Solutions Emerge

31st Jan 2017

A patient undergoes a full physical exam as part of an attempt to detect and treat non-communicable disease supported by Novartis Access. Photo: Bedad Mwangi

A patient undergoes a full physical exam as part of an attempt to detect and treat non-communicable disease supported by Novartis Access. Photo: Bedad Mwangi

 

By David J. Olson

As 2017 begins, we celebrate the fact that many diseases of developing countries have been significantly reduced in recent years. The numbers of people suffering from HIV, malaria and tuberculosis are in decline.

But as communicable diseases wane, non-communicable diseases (NCDs) wax (like cancer, diabetes, cardiovascular and chronic respiratory diseases).

This was hammered home by the Institute for Health Metrics and Evaluation (IHME) of the University of Washington which, just in the last two months, released three new reports that provide further evidence of this trend:

• Almost 20% of global deaths in 2015 were linked to elevated blood pressure, according to the latest Global Burden of Disease study. The number of people in the world with high blood pressure, including hypertension, has doubled in the past two decades, putting billions at increased risk for heart disease, stroke and kidney disease.

• Cancer is growing almost everywhere in the world but the greatest increase between 2005 and 2015 occurred in the poorest countries that are least equipped to deal with it, according to a new analysis.

• 30% of all deaths from diabetes worldwide occur in the poorest countries bringing a double burden of disease – from communicable and non-communicable disease – to many countries in Africa, according to a new IHME report. Women often bear most of the burden.

Of course, NCDs are not a new problem. However, they are increasing both in scale and visibility because of the transition from low-income to middle-income status, the influence of globalization on diet and consumption patterns and greater longevity as people increasingly survive childhood illness and communicable disease, according to an analysis by the Kaiser Family Foundation.

Despite the rising tide of NCDs, though, little money has been invested to prevent and treat them. In Financing Global Health 2014, IHME said that development assistance for health (DAH) directed towards NCDs is one of the smallest health focus areas they estimate and was only $611 million in 2014, just under 2% of total DAH. The first graph on page two of this brief shows just how little NCDs are funded compared to communicable disease and child health.

“The productivity loss for NCDs is estimated to be $500 billion annually yet almost no donor funding is being deployed against them,” said Dr. Harald Nusser, global head of Novartis Access and Novartis Malaria Initiative. “We need robust funding for both communicable and non-communicable disease, and more robust health systems in general to start turning our efforts towards NCDs while not relenting in the fight against AIDS, malaria and tuberculosis.”

“NCDs share all the ideological and social justice issues of HIV but cause 30 times more deaths and receive 17 times less funding,” writes Luke N. Allen and Andreas B. Feigl in a new commentary in The Lancet Global Health.

Even communicable disease experts see how the disease burden is shifting to NCDs. Charles Nelson, chief executive of the Malaria Consortium, talks about how malaria death have fallen between 2000 and 2015 while NCDs are rising. Nelson said disability-adjusted life years (DALYs), which is a measure of overall disease burden, coming from communicable maternal, perinatal and nutritional diseases is decreasing while DALYs from NCDs is increasing, said Nelson. This is true globally, as well as in Africa and Southeast Asia.

Kenya seems to be the focus of much of the research as well as some of the earliest attempts to deal with NCDs in Africa.

A report on the burden of disease in Kenya found that the country has made tremendous progress in dealing with communicable disease and maternal and child health but that the burden of NCDs was growing, with the health loss from NCDs growing from 19% in 2000 to almost 30% in 2013.

Three new efforts, all led by pharmaceutical companies, are trying to address NCDs in Kenya:

• In 2015, Nusser helped launch Novartis Access which makes 15 on- and off-patent medicines available to treat NCDs at $1.00 per treatment per month.

• AstraZeneca’s Healthy Heart Africa program conducted one million hypertension screenings in Kenya, opened over 250 health facilities, trained over 2,600 health care workers, diagnosed close to 150,000 patients with high blood pressure and started treatment for 25,000 patients in its first year.

• Novo Nordisk is expanding its Base of the Pyramid Project, a sustainable initiative rolled out in 2010 to facilitate access to diabetes care for the working poor in low- and middle-income countries. The project has screened more than 20,000 people for diabetes.

And a major initiative involving 22 biopharmaceutical companies just launched Access Accelerated, a global initiative to increase access to NCD prevention and care in low- and lower-middle income countries, at the World Economic Forum on Jan. 18. Access Accelerated is supported by $50 million in funding and a pledge of increased individual company programs focused on NCDs.

The NCD movement has long been hobbled by its unwieldy name – non-communicable diseases. “A name that is a longwinded non-definition, and that only tells us what this group of disease is not, is not befitting of a group of diseases that now constitute the world’s largest killer,” writes The Lancet Global Health, which calls for a change in terminology (and offers a few suggestions) to bring needed and deserved attention to these diseases.

 

 

The End of Trachoma, World’s Leading Cause Of Preventable Blindness, Is in Sight

13th Dec 2016

This woman, who has just been examined by a local health worker at a clinic in Ressa Kebele, Kallo District, Amhara, Ethiopia, will receive trichiasis surgery. The arrow indicates which eye will be operated on. Credit: The Carter Center.

This woman, who has just been examined by a local health worker at a clinic in Ressa Kebele, Kallo District, Amhara, Ethiopia, will receive trichiasis surgery. The arrow indicates which eye will be operated on. Credit: The Carter Center.

By David J. Olson

In 1988, as a young development worker for Lutheran World Relief in Mali, I was showing a group of American Lutherans our development projects in Dogon Country, when we came across a tragic situation a young boy with a severely inflected eye, where he had lost his sight, with menacing flies hovering around the other, still good eye.

It was a heart-wrenching scene for these people, most of whom were on their first trip to Africa. One woman took pity on the boy and, after returning to the U.S., raised money for his treatment. I took the boy to the best hospital in the country in the capital Bamako. Doctors removed his infected eye, and replaced it with a glass eye. Without treatment, he surely would have gone completely blind.

That was my first exposure to trachoma, the world’s leading infectious cause of blindness in the world. Trachoma a bacterial eye infection found in poor, isolated communities lacking basic hygiene, clean water and sanitation – continues to plague Mali and 40 or so other countries.

What is trachoma? It is a disease of the eye caused by infection with the bacterium Chlamydia trachomatis that is spread through personal contact and by flies that have been in contact with discharge from the eyes or nose of an infected person. If the infection persists, the inside of the eyelid becomes so scarred that it turns inward and causes the eyelashes to rub on the eyeball, causing pain, discomfort and permanent damage to the cornea.

The World Health Organization estimates that trachoma is responsible for the blindness or visual impairment of 1.9 million people in 42 countries, with just over 200 million people at risk of trachoma blindness.

The Carter Center, best known for its work on Guinea worm (which is close to elimination), is now focusing on its next miracle – the elimination of blinding trachoma by 2020. The Center works to control and prevent trachoma in six of the 31 countries actively implementing a prevention strategy (Ethiopia, Mali, Niger, Sudan, South Sudan and Uganda).

Just last month, WHO declared Morocco to be the eighth country to eliminate trachoma as a public health problem. The other countries are China, Gambia, Ghana, Iran, Mexico, Myanmar and Oman.

The Carter Center says that in order to eliminate blinding trachoma, all four components of the SAFE strategy must be implemented: Surgery for advanced disease, Antibiotics to clear infection, Facial cleanliness and Environmental improvement to reduce transmission (particularly, improving access to water and sanitation).

In September in Washington, D.C., the Carter Center screened a documentary film from award-winning producer Gary Strieker and Cielo Productions called “Trachoma: Defeating a Blinding Curse,” in which a film crew followed Carter Center staff and other health professionals around Ethiopia for seven years in the Amhara Region, Ethiopia, the most endemic region of the most endemic country.

Strieker, a former CNN correspondent based in Africa, talked about the power of the story of the fight against trachoma.

“Most of the stories I covered in Ethiopia over the years were not very encouraging – famines, droughts, revolutions,” he recalled. “Ethiopia was always in the portfolio – one of those hopeless cases where you could be sure that whatever was coming out of Ethiopia would be bad. People had no hope. You could see it wherever you went.”

“But as we watched the trachoma campaign develop, the sustained effort by the government and the people to carry this out, we saw thousands of health workers mobilized, so much enthusiasm and making it happen in front of our eyes, year after year. They set an example for the rest of Africa and the developing world. It’s a great testament to what can be done if the government has the political will and actually reaches the people and gets them to work in their own interests. It’s been so encouraging and such a wonderful story.”

Kelly Callahan, the Carter Center director of the Trachoma Control Program, said that the trachoma campaign success happened because it was done with a “bottom-up structure.”

“The government is not telling people what to do, when to do it and how to do it,” she said. “It’s the people that are driving the force. If the people are driving it, they own it, they feel empowered and they feel they’re doing something together. If the community doesn’t own the program, then it’s not sustainable and it will not improve their lives.”

Trachoma foes believe the goal of elimination by 2020 is realistic even though much works remains to be done. A massive mapping exercise was conducted in 2013 to help understand better the scale of the problem outside of the Carter Center-assisted countries. Since then, activities have increased in most of these places. The Carter Center-assisted countries should achieve 2020 goal, Callahan said, through a strong commitment of the government in each country, the communities, the partners and the global alliance.

Trachoma control is not only the moral thing to do, it makes good economic sense. Trachoma prevention and treatment is one of the best buys in global health, according to Paul Emerson of the International Trachoma Initiative. Every dollar invested in trachoma reaps thousands of dollars in savings, Callahan said.

Callahan thinks the elimination of trachoma will have an impact beyond trachoma. “If someone’s suffering from trachoma, they’re probably suffering from river blindness, probably co-endemic for schistosomiasis, soil-transmitted helminths and lymphatic filariasis. If you pile on these diseases, their immune systems are so suppressed that HIV, TB and malaria – the big killers – can come in. So if we can get rid of Guinea worm and trachoma and pluck every single one of these diseases, imagine immune systems that are not suppressed from neglected tropical diseases. Just think of the quality of life. That’s immeasurable.”

Polio’s Days Are Numbered As Teams Close in on Last Few Cases in 3 Countries

23rd Nov 2016

By David J. Olson

Khuram and Latif, on left, were two of the polio heroes of Pakistan honored at a World Polio Day event at the Pasteur Institute. Khuram works for Sanofi Pasteur, the main polio vaccine supplier; Latif is a polio vaccinator who was shot in 2012. Jim Costello, on right, contracted polio in 1958. His lungs are 75% paralyzed and he uses a medical ventilator 18 hours a day. He has fought for polio survivors since 1993 and was also honored as a polio hero. Photos by David J. Olson

Khuram and Latif, on left, were two of the polio heroes of Pakistan honored at a World Polio Day event at the Pasteur Institute. Khuram works for Sanofi Pasteur, the main polio vaccine supplier; Latif is a polio vaccinator who was shot in 2012. Jim Costello, on right, contracted polio in 1958. His lungs are 75% paralyzed and he uses a medical ventilator 18 hours a day. He has fought for polio survivors since 1993 and was also honored as a polio hero.  Photos by David J. Olson

 

By David J. Olson

PARIS, France In 2012, Latif and his colleague were vaccinating children against polio in Pakistan when they were shot by extremists. Latif was shot in the leg. He had 11 metal rods inserted into his leg and was hospitalized for three months. His colleague died. Today, fully recovered and undeterred, Latif (his surname is withheld to protect his security) continues his anti-polio crusade in northwestern Pakistan.

Jim Costello, 73, contracted polio at the age of 15. It paralyzed his upper body: He has triple curvature of the spine, wears a spinal brace and has no use of his arms. His lungs are 75% paralyzed and he uses a medical ventilator for about 18 hours daily. He lives at home in Dublin, Ireland with his wife Delia, “my beloved partner of over 30 years,” on the weekends. During the week, he is in the hospital where he still uses an iron lung. Despite these limitations, he has led a productive life in the retail clothing business and in support of polio survivors. Since 1993, he has served as chairperson and board member of Post-Polio Support Group Ireland

Latif and Costello were two of five people honored as “polio heroes” at a World Polio Day event Oct. 24 at the Pasteur Institute here sponsored by Sanofi Pasteur and Rotary International, two organizations deeply invested in the fight against the disease. Meet Latif in this video and Khuram (an employee of Sanofi Pasteur) in this video (videos from Sanofi Pasteur/AKS Films).

Participants heard experts say that the world is tantalizingly close to eliminating polio, and that elimination could happen in 2017. As of last week, there were only 32 remaining cases of wild poliovirus 16 in Pakistan, 12 in Afghanistan and 4 in Nigeria.  We are on the brink of eliminating the second human disease in history (smallpox, in 1980, was the first).

It is true that all three countries have security challenges. But in Pakistan, the country with the largest number of remaining cases, the security situation has improved markedly since 2014.

“There were close to half a million kids not reachable due to insecurity in 2014,” said Dr. Mufti Zubair Wadood, technical officer for the Global Polio Eradication Initiative at the World Health Organization (WHO) and former head of the WHO polio program in Pakistan. “Since then, the situation has been improving and right now there are almost no areas of the country that are not accessible. That has resulted in a significant drop in the number of cases. Pakistan deserves a huge pat on the back at a time when things were dire.”three countries have security challenges. But in Pakistan, the country with the largest number of remaining cases, the security situation has improved markedly since 2014.

Wadood believes the next six months presents an excellent opportunity because this cooler period is when the vaccine works best and the virus is not transmitting at a high rate. “If good campaigns are implemented in the next 3-6 months, there is no reason we cannot stop it in late 2016 or early 2017,” said Wadood.

The polio eradication campaign is the largest public health program in history. For nearly 30 years, national governments, WHO, Rotary International, the U.S. Centers for Disease Control and Prevention and UNICEF have worked on this issue. More recently, the Bill and Melinda Gates Foundation joined the effort.

Sanofi Pasteur is, by far, the biggest supplier of polio vaccine in the world. It has provided 6 billion doses of the oral polio vaccine over the last decade and more than 1 billion doses of the inactivated polio vaccine, through injection, which will protect people once polio is eradicated.

But polio vaccination will continue for years after eradication, said David Loew, executive vice president of Sanofi Pasteur. Loew said that Sanofi is even considering building a second factory in order to develop the production capacity necessary to produce the injectable version.

Polio eradication is not only a global health success but also an economic success. Eradication is expected to save between $40 and $50 billion during the period 1988 to 2035, according to Dr. Kimberly Thompson, professor of Preventive Medicine and Global Health at the University of Central Florida. “Polio eradication represents a gift from our generation to future generations.”

Elimination may be near but Latif, the Pakistani polio hero, is not ready to declare victory quite yet. “I want the children of my country to be healthy and protected from polio. I have participated in this fight from the beginning and I want to continue to the end, to see a polio-free Pakistan.”

Did he consider giving up after extremists shot him in 2012? “No, I never thought of that,” he said. “As a matter of fact, I don’t connect the pain I felt with the work I do. They are two different things in my mind.”

Costello, the indefatigable polio survivor wanted to make two points:

If the people who attack vaccination teams could see me and people like me, is that really how they would like their own children to live their lives?

“I would like to appeal to the WHO, Rotary International and other organizations working to eradicate polio. When their job is done, which I know will be soon, would they please consider turning their valuable efforts towards the millions of polio survivors, particularly in underdeveloped countries, that now face the problems associated with post-polio syndrome?”

 

New Test to Detect HIV In Babies Boosts Hope Of Meeting UN Targets

25th Oct 2016

Dr. Landon Meyer of the University of Cape Town takes a blood sample from the heel of an infant using the Alere q HIV-1/2 Detect rapid HIV test. The results become available in less than one hour.

Dr. Landon Meyer of the University of Cape Town takes a blood sample from the heel of an infant using the Alere q HIV-1/2 Detect rapid HIV test. The results become available in less than one hour.

By David J. Olson

When Saquina, a 38-year-old single mother living in Nacala Porto, Mozambique, learned she was HIV positive while pregnant, she thought her life was over. Instead, she decided to accept her HIV status and follow the advice of the nurse who counseled her.

She did not miss any visits to the health center. She took the pills that helped prevent transmission of the virus to her unborn child. She participated in support groups with other HIV-positive mothers. When her son Frenchou was born, she gave him medication every day and breastfed him exclusively for six months.

When he was two years old, Frenchou was tested for HIV and found negative another of many recent successes in the prevention of mother-to-child transmission (PMTCT), according to the Elizabeth Glaser Pediatric AIDS Foundation.

Between 2009 and 2015, there was a 60% decline in new HIV infections in children in the 21 priority countries, according to a UNAIDS report released in June. Seven of those countries reduced infections by more than 70%. A total of 1.2 million new infections among children were averted in these countries.

But if you thought thought that all is now well with PMTCT, and that we can move on to other HIV challenges, you would be mistaken. While a 60% drop is certainly encouraging, it is significantly below the 90% target set by the World Health Organization (WHO). UNAIDS has set a goal of eliminating all new HIV infections among children by 2020 while ensuring that 1.6 million children have access to HIV treatment by 2018.

Every day, an estimated 400 children are infected with HIV. When children with HIV are not diagnosed and treated promptly, as many as one-third will die before their first birthday and half before their second birthday.

But to achieve this goal, early infant diagnosis has been a major stumbling block. Up to now, infant testing has imposed a lag time between the test and the results of 3 to 6 weeks.

We know that if mothers and babies have to return to the clinic for test results weeks later, they are less likely to get the results and start treatment. “About 50 percent of infants who are tested do not receive their test results and, of those children who test positive, 40 percent never receive treatment,” notes the Elizabeth Glaser Pediatric AIDS Foundation.

That’s why a new technology for testing infants in less than one hour is so exciting. Alere, a U.S.-based company in rapid diagnostic products and services, says the test called the Alere q HIV-1/2 Detect is the first ever molecular diagnostic that identifies HIV-1 and HIV-2 in a health facility (Alere calls this “point-of-care testing”) in less than one hour. The technology allows HIV-positive babies to be put on treatment immediately. It also eliminates the problem of mothers not returning to the clinic for their test results.

Alere believes point-of-care testing will accelerate testing of infants, especially in South Africa, which has the highest HIV burden in the world. Currently, an estimated 11.2% of the population is living with the disease. South Africa is piloting the test in two health centers in the Western Cape.

“Currently, most newborns in developing countries are screened for HIV infection via dry blood spot testing, but because health workers have to wait 3 to 6 weeks for results many potentially HIV-positive infants are lost to follow-up and remain untreated,” said Dr. Landon Meyer, a professor at the School of Public Health and Family Medicine at the University of Cape Town. “The ability to provide to a patient’s mother a definitive test result when before we would often conduct a test and mothers wouldn’t come back the ability to provide that on-site within 52 minutes really is an epiphany. It’s a revelation.”

“There have been massive successes in PMTCT over the last decade, particularly in South Africa, but what we realize more and more is that the battle is not won and it’s going to be a very long time before we eradicate pediatric HIV infection, and so technologies like the [Alere] q become more important to us in practice.”

Pilots are also taking place in Malawi and Mozambique, and Kenya is looking at the possibility of using this test.

In June, Alere won prequalification from WHO, meaning the technology can be widely implemented by organizations and governments, and used by health workers to diagnose HIV infections rapidly, allowing for a more timely initiation of anti-retroviral therapy.

Anti-retroviral treatment is very effective in children with HIV, transforming it from a death sentence to a long-term, manageable condition, according to NAM. Many experts believe that treated children will have almost normal life expectancy.

If we can improve diagnostics and treatment, and deliver them to those children who need them, we will have more happy endings, like the inspiring 21-year-old Lerato, from South Africa, who was born with HIV. Now she says “There’s more to life than HIV. It’s not stopping me. I can do anything I want.”

A Long, Hard Road to Reversing Stagnation of Family Planning in Nigeria

27th Sep 2016

DKT Bee Lydia, a community health worker, gives Iya Lekan a Sayana Press injectable contraceptive at her house. She has five children and does not want any more, at least for now.  Photo by David J. Olson

DKT Bee Lydia, a community health worker, gives Iya Lekan a Sayana Press injectable contraceptive at her house. She has five children and does not want any more, at least for now.
Photo by David J. Olson

 

By David J. Olson

LAGOS, Nigeria Lydia, a community health worker for DKT Nigeria, steps carefully as she navigates the grimy streets of Makoko, one of the worst slums of Lagos. She is trying to avoid mud or something worse. The sanitation is abysmal. But Lydia is on a mission to bring contraception to some of the most disadvantaged women in Nigeria.

This day, she calls on Iya Lekan. Although neither Iya, 36 years old, or her husband have regular work or specific sources of income, they have five children to look after.

“I don’t know how many times I have given birth,” she says in Yoruba, the local language here. “I’m tired.”

Iya told Lydia she was ready to start practicing family planning. Lydia presented various options, and Iya chose a three-month injectable called Sayana Press. Lydia immediately gave her the injection in her upper thigh.

Some people think Sayana Press could be a game-changer. It’s a new version of the well-known Depo-Provera injectable contraceptive, but contains 30% less of the active ingredient and can be administered by lesser-skilled health workers. The United Kingdom has already approved it for self-injection.

Last month, I spent an afternoon with Lydia, a member of the DKT Bees, a group of community health workers (CHWs) who focus on family planning in some of the grittiest parts of Lagos. DKT calls their CHWs “bees” because they are like the hard-working insects that go from flower to flower spreading pollen. But instead of pollen, DKT Bees go house to house counseling, educating and dispensing contraceptives.

The road to greater contraceptive use in Nigeria has not been smooth. It’s shocking that the percentage of married women using modern contraception in Nigeria is only 9.8 percent (Nigeria Demographic & Health Survey 2013). That figure is lower than all countries in West Africa except Gambia, Guinea and Mauritania, according to the 2016 World Population Data Sheet, and has has hardly changed in the last ten years. Nigeria has a population of 187 million, making it the seventh largest country on earth. If current trends continue, it will be tied for third, with the United States, in 2050.

Clearly, family planning has stagnated in Nigeria since 1999. The reasons are many but certainly family planning myths and misinformation play a huge role. A DKT outreach worker told me that some of the most common questions she gets from Nigerian women are:

  1. What are the side effects of each method?
  2. Does family planning result in infertility?
  3. Does family planning increase body weight or make me fat?
  4. What do I do if bleeding occurs?
  5. Does contraceptive use predispose me to cancer?

The bottom line is that contraceptives are good for the health of women. In fact, Nigerian health experts blame the low uptake of family planning as one of the reasons why Nigeria still reports high maternal mortality.

The good news is that 16.1% of married women in Nigeria who are not using family planning want to start using it. The figure is even higher among sexually active unmarried women: 21.8 percent of them want to use contraception.

World Contraception Day on Sept. 26 provides a good opportunity to reflect on the current situation and what we can do to improve it in places like Makoko, so that every Nigerian woman who wants contraception can access it.

Decades of research have shown that modest investments in family planning can save lives and improve maternal and child health. And consider that family planning has been proven to be one of the most cost-effective health interventions. In short, family planning improves the economic well-being of families, communities and nations.

DKT Bees are one of the programs of DKT Nigeria, an affiliate of DKT International. DKT came to Nigeria in 2013 to help change the family planning paradigm. Using social marketing, it launched Kiss and Fiesta condoms, Postpill emergency contraception, Levofem oral contraceptive, Sayana Press injectable, Implanon NXT and Jadelle implants, Lydia intrauterine devices (IUDs) and Miso-Fem (Misoprostol). After only three years, it contributed 14% of Nigeria’s contraceptive prevalence rate in 2015.

Dimos Sakellaridis, the country director of DKT Nigeria, says he wants to make affordable contraceptives as easily available in Nigeria as Coca-Cola.

“Like women’s beauty products or hairstyles, modern family planning should be consumer-oriented and easy to understand, access and use,” he says. “When a woman wants to feel beautiful, she walks to a nearby store and buys a beauty product or service. Family planning should be obtained for the same consumer benefits to enable women to feel beautiful by allowing them to manage their fertility and life.”

DKT Nigeria launched a new family planning communications campaign that coincides with World Contraception Day on Sept. 26. The target audience of its campaign is young women ages 18-34 (primary) and young men ages 20-34 (secondary) in the lower middle and working classes of southwest Nigeria. A new website, Honey and Banana, will serve as the central hub of the campaign and will be the destination for other traffic sources, such as Facebook, Twitter and Instagram.

The theme of the campaign is “Be Sharp.” The phrase is common slang that resonates with the target audiences. It means be smart, not dull. It means making the right decisions, especially concerning birth control and contraception, to avoid unwanted surprises.

Almost one in five people living in sub-Saharan Africa is a Nigerian. If enough girls and women are motivated to adopt contraception, the government will meet its goal of reaching 36% contraceptive prevalence rate by 2018, and their health will improve. It all comes down to community health workers like Lydia and the DKT Bees, going from house to house, taking one step at a time, to meet the needs of disadvantaged Nigerian girls and women.

DKT Bee Lydia (center) in the Lagos slum of Makoko, with "Queen Bees" Mary and Julian, registered nurses who supervise the team of Bees. Photo by David J. Olson

DKT Bee Lydia (center) in the Lagos slum of Makoko, with “Queen Bees” Mary and Julian, registered nurses who supervise the team of Bees. Photo by David J. Olson

The Next Great Pandemic: What Will It Look Like and Where Will It Come From

23rd Aug 2016

Pandemic: Tracking Contagions, from Cholera to Ebola and Beyond

Pandemic: Tracking Contagions, from Cholera to Ebola and Beyond

By David J. Olson

A few years ago, in a survey by epidemiologist Larry Brilliant, 90 percent of epidemiologists said that a pandemic that will sicken 1 billion, kill up to 165 million and trigger a global recession that could cost up to $3 billion would come in the next two generations. Currently, we’re living through three pandemics HIV, Zika and cholera. What will the next pandemic look like and where will it come from?

Those are some of the questions science journalist Sonia Shah attempted to answer in an event marking the centennial of the Johns Hopkins University’s Bloomberg School of Public Health and in her book “Pandemic: Tracking Contagions from Cholera to Ebola and Beyond,” published earlier this year. The book should be required reading for anyone interested in the future of global health.

Shah spent six years trying to figure out how microbes turn into pandemic-causing pathogens. She looked at the history of pandemics, particularly cholera because it’s one of our most efficient pandemic-causing pathogens. She went to places where new pathogens are emerging to try to figure out what are the political and social drivers that push these microbes into human populations.

She found that one of the major drivers is wildlife. A disproportionate number of human pathogens come from other primates, who’ve given us 20 percent of our most burdensome pathogens (including HIV and malaria).

“About 60% of the new pathogens are emerging in animals,” she said. “Over 70% of those come out of wild animals. From bats, we’ve gotten Ebola, Nipah, SARS and Marburg, from birds we’ve gotten Avian influenza and West Nile virus, from rodents we’ve gotten Monkey Pox and Lyme Disease, from monkeys we’ve gotten malaria and HIV and probably Zika.”

The expansion of the human population is destroying wildlife habitat and this results in the remaining wildlife crowding in ever closer to humans.

“We’re creating more and more interfaces between humans and wildlife that allows for novel, more intimate kinds of contact in which the microbes that live in their bodies, can spill over into our bodies,” she said.

And animals, as well as humans, are crowding together. Shah says we have more animals under domestication today than in the last 10,000 years of domestication until 1960 combined. And an increasing proportion of these animals are living on factory farms, which she calls “the animal equivalent of slums, where you have hundreds of thousands of animals crowded really closely together where they’re breathing on each other, touching each other and being exposed to each other’s wastes. This is another opportunity new pathogens are exploiting.”

This new sanitary crisis is in addition to our old sanitary crisis in which 2.6 billion people don’t have access to any modern sanitation. In this new crisis, livestock produces 7 billion tons of excreta every year, which is far more than our crop lands can absorb. So we have giant open cesspools of untreated animal waste, which seeps into the environment.

And we’re spreading these pathogens around more efficiently than ever with extensive flight networks. Consequently, Shah says, even when one of these pathogens emerges in a place where there’s not a lot of susceptible people, it can quickly travel to a place where there are, to such an extent that we can predict where a pathogen will strike next by measuring the flights between infected and uninfected cities.

Since a lot of these pathogens are coming out of animals and driven through human populations by social and political factors, you would think that the best way to tackle this problem would be through an interdisciplinary approach. “Get the veterinarians, wildlife biologists, ecologists, engineers, anthropologists, political scientists, economists and bio-medical specialists together to look at the entire process,” she said. “But of course, that’s not what we do. We approach infectious outbreaks as solely a bio-medical phenomenon, reducing it to its smallest components, and then striking it down with surgical precision.”

Shah pointed out that Brilliant didn’t have a crystal ball. He was merely a warning of what will happen if we don’t change. She believes there is a lot that we can do with early detection, as this article points out. We don’t have to wait for the vaccines and drugs.

Ultimately, she said, we have to reduce the conditions that allow pandemics to occur, things like restoring wild habitats, so the microbes in animals stay in animals and do not cross over into humans. We have to protect the health of the most vulnerable among us, people who live in slums and animals in factory farms.

“We need to reimagine our relationship to the microbial world,” she said. “There is no ‘us’ and ‘them’ anymore. This is their planet, and they were here first. And they’re a lot better at living here than we are. We have to recognize that our health is connected to the health of our societies but also the health of our animals, our wildlife and our ecosystems.”

So what will the next pandemic look like? Shah says we don’t have a great track record predicting pandemics (no one predicted Zika) but sees two scenarios as the most likely:

1) A novel form of influenza, because influenzas are so efficient at spreading that even a slight increase in mortality from a virus would result in a huge number of deaths; or

2) An antibiotic-resistant bacteria, which poses a huge threat to public health because even a common injury like a scratch can become life threatening.

Shah says there is one thing that lets her sleep. “Look at it from the pathogen’s point of view. They need to transmit from one person to another but if they kill you too fast, they’re not going to be able to transmit very well. That helps me sleep.”

Controversy Brewing Over The Greatest Barriers to Access to Medicines

16th Aug 2016

A worker selects medicine from MEDS (Mission for Essential Drugs and Supplies) warehouse in Nairobi. MEDS is jointly owned by the Kenya Conference of Catholic Bishops and the Christian Health Association of Kenya. Photo: Bedad Mwengi

A worker selects medicine from MEDS (Mission for Essential Drugs and Supplies) warehouse in Nairobi. MEDS is jointly owned by the Kenya Conference of Catholic Bishops and the Christian Health Association of Kenya. Photo: Bedad Mwengi

 

By David J. Olson

In comments last week at the International AIDS Conference in Durban, South Africa, UN Secretary-General Ban Ki-moon said four things deserved credit for getting the AIDS pandemic under control people living with HIV, biomedical companies, generic medicines and international finance.

But despite his gratitude to biomedical companies and generic medicines, the Secretary-General is overseeing a process that may threaten to undermine those companies’ ability to improve access to medicine in developing countries.

The World Health Organization says an estimated 2 billion people (27% of the world’s population of 7.5 billion) lack access to essential medicine, most of them in Africa and Asia, and a full three-quarters of the world’s population (around 5.5 billion) have no access to proper pain relief treatment.

To address this staggering problem, the Secretary-General set up a High-Level Panel on Access to Medicines earlier this year. The purpose of the panel was “to review and assess proposals and recommended solutions for remedying the policy incoherence between the justifiable rights of inventors, international human rights law, trade rules and public health in the context of health technologies.”

Sounds like a great and noble idea, right? But some expert commentators think the panel is on track to do more harm than good because of its terms of reference.

Secretary-General Ban Ki-moon told the panel to focus on intellectual property and the pharmaceutical companies’ protection of patents and ignore the other issues that hamper access to medicine weak health systems, questionable government policies and a lack of doctors, nurses and community health workers.

Reports like this one suggest that the panel not only attacks the patent system but proposes to put the United Nations in charge of drug development. The High-Level Panel has said that the leaks may not be accurate and that the panel is still actively working on the report. The High-Level Panel was contacted for comment but did not respond before this article was published. When it is released, the report will be published on the panel’s official website.

There are so many more issues that influence access to medicines than intellectual property and patents. Some would argue that patents are not an obstacle to health at all but a tool to promote health.

“Far from being a threat to public health, patents are indispensable to promoting life-saving medical research,” writes Joseph Allen, who consults on intellectual property and formerly headed the National Technology Transfer Center.” If companies couldn’t protect their inventions through intellectual property laws, they’d have little reason to take the enormous risks involved in drug discovery. It’s not a coincidence that drugs are only created in a few countries with strong patent systems.”

And Dr. Kristina Lybecker, an associate professor at Colorado College, writes that patents not only foster pharmaceutical innovation, but also inhibit counterfeiting and fake drugs, which are widely recognized as serious barriers to access to high-quality drugs.

In recent interviews conducted by Baird’s CMC Ltd. with nine high-level Kenya public health professionals, none of them mentioned intellectual property as a key barrier to access to medicines. The two most common responses were weak health systems and cost of medicines and doctor consultations. Other reasons included late diagnosis, sub-standard drugs and a lack of health-seeking behavior on the part of the patients.

“Many times, consultancy fees are more expensive than the medicines,” said Professor Isaac Kibwage of the College of Health Sciences, University of Nairobi. “It is a bigger barrier in access to medicine.”

Similarly, in Senegal, three public health officials interviewed did not identify intellectual property as as issue but all of them identified cost of doctor visits or user fees for diagnostics.

Of 16 people active on pharmaceutical issues interviewed by Fundamento RP, a Brazilian qualitative market research consultancy, only one of them (described as an AIDS activist) identified patents as a problem. Three of them specifically said patents were not the problem.

Taila Lemos, the founder of Gentros, the Campinas Start Up, the Beta Lounge consulting innovating and Corporate Garage has a long history in the pharmaceutical field in Brazil. She said that the panel should have had more industry participation — the two Brazilians on it are very qualified, but are both from government, and the panel needs people who have actually developed medicines in the private sector.

“Here in Brazil we have people who say they are experts in Amazonia forests but they have never set foot in the Amazon,” she says. “It’s the same thing with this panel.”

She said patents are the drivers of innovation. “We developed four vaccines for animal health. It took 10 years to bring them to market. If we don’t have the protection of intellectual property, no one will invest in the development of these drugs.”

Kenya Starts to Shift Focus To Chronic Diseases While Not Relenting in HIV Fight

28th Jun 2016

A patient at a rural health camp in Mwae County, Kenya has his blood pressure checked as part of a full physical exam. If he needs hypertension treatment, he will get it as part of the cost of the camp. Photo: Bedad Mwangi

 

By David J. Olson

For some time, huge disparities between global health spending and the global disease burden have raised concerns that this funding was not being allocated based on the evidence. That is, money was not always going where the disease burden was greatest.

The Institute for Health Metrics and Evaluation (IHME) has pointed out that the disparities are most extreme in HIV/AIDS on the high end and non-communicable diseases (NCDs) on the low end.

As the toll from communicable diseases like AIDS and malaria decline and people live long enough to get NCDs, we need to invest more in fighting NCDs (also called “chronic diseases”) and reduce these glaring disparities between global health spending and disease burden. Countries like Botswana, Eritrea, Kenya Malawi, Mozambique, Rwanda, South Africa, Swaziland, Tanzania, Uganda, Zambia and Zambia all countries that increased their treatment coverage by more than 25% between 2010 and 2015, according to UNAIDS now have to pivot to NCDs without taking their eyes off of HIV.

Kenya is an excellent case in point. Life expectancy there peaked in 1987, and then went down in the 1990s, as AIDS made its presence felt. But as more Kenyans have gotten AIDS treatment and new infections declined, life expectancy started going up again, and is expected to return to its historic peak of 60 years in 2017, according to a World Bank blog.

That’s great news but that silver lining contains some bad news: Some people are now living long enough to get an NCD like cardiovascular and respiratory disease, diabetes and cancer.

Annually, 28 million people die from NCDs in low- and middle-income countries, representing nearly 75% of deaths from NCDs globally. Health programs, therefore, must turn their attention to this new pandemic without losing focus on the existing AIDS pandemic. And donors and governments must follow suit with funding that is in synch with the disease burden and not based on 1990s realities.

Dr. Samuel Mwenda is a seasoned soldier against both pandemics. For 13 years, as the general secretary and CEO of the Christian Health Association of Kenya, a network of Protestant church facilities in Kenya, he has led CHAK’s approach to HIV/AIDS prevention, care and treatment.

CHAK has made significant contributions to the national fight against AIDS in the four most populous provinces of the country and now supports over 41,000 clients with antiretroviral therapy, representing about 9% of the total number of patients nationally. Kenya now has the second largest treatment program in Africa (after South Africa), with nearly 900,000 people on treatment at the end of 2015.

CHAK has helped Kenya become an AIDS success story. UNAIDS says that Kenya is one of the countries “showing the most remarkable progress in expanding access to antiretroviral medicines and reducing the number of new infections.”

Several years ago, CHAK turned its attention to the emerging pandemic of NCDs, and began working on hypertension and diabetes. Seventy percent of the global cancer burden is in low- and middle-income countries like Kenya, where the probability of dying between the ages of 30 and 70 from one of the four main NCDs is 18%. NCDs account for 27% of deaths in Kenya, according to the World Health Organization.

In 2015, with the support of Novartis Access, CHAK started offering a portfolio of products to treat diabetes, hypertension, asthma and breast cancer at an end price not to exceed $1.50 per treatment per month. The program is currently in three counties of Kenya and is expected to be in all 47 counties by the end of 2017, and followed soon by Ethiopia, Rwanda and Senegal. The program hopes to be in 30 countries by 2020, depending on government and stakeholder demand.

Novartis Access calls its program a “social business,” which it expects to eventually create value, not only for society but also for Novartis.

“A key learning from HIV programs was that you cannot build awareness until there is treatment,” said Mwenda. “It’s the same with NCDs. It’s access to treatment that gets individuals and families to learn about heart disease and diabetes and to come forward for diagnosis. When people see others in their communities living long, healthy and productive lives despite NCDs, it makes them more willing to invest their own time and resources in treatment.”

“Africa is rapidly overcoming the challenges of infectious diseases,” said Mwenda. “Much of that is due to the commitment of faith-based organizations, that  provide about half of all health care in the countries south of the Sahara. I believe that the same God-given mandate that we had to conquer polio and AIDS requires us to get serious about diabetes and cancer.”

On June 19, Mwenda became the third recipient of the Christian International Health Champion Award, which honors an individual who has dedicated his/her life to global health from a Christian perspective and has made significant contributions to the field and to Christian Connections for International Health (CCIH), which presented him with the award. Full disclosure: David J. Olson is a board member of CCIH.

Millions Saved Shows That Global Health Programs Can Achieve Success

24th May 2016

A child receives a MenAfriVac Meningitis A vaccination in Burkina Faso, the first country to roll out the vaccine in 2010. By the end of 2013, more than 135 million people had been vaccinated with MenAfriVac in 12 countries. The MenAfriVac vaccination campaign is one of the success stories described in "Millions Saved." Credit: PATH

A child receives a MenAfriVac Meningitis A vaccination in Burkina Faso, the first country to roll out the vaccine in 2010. By the end of 2013, more than 135 million people had been vaccinated with MenAfriVac in 12 countries. The MenAfriVac vaccination campaign is one of the success stories described in “Millions Saved.” Credit: PATH

By David J. Olson

If you are reading this article, you probably already believe in global health, and its ability to improve the quality of life and save lives. Every month we tell some of these stories here at Global Health TV.

But some people do not believe that global health programs work or, perhaps, are just indifferent to that fact. The Kaiser Family Foundation recently released a survey of the U.S. general public that showed that the visibility of U.S. global health effort are declining – only 36% have heard a lot or some about U.S. efforts in the past year, down from 57% in 2010.

That’s why books like “Millions Saved: New Cases of Proven Success in Global Health,” written by Amanda Glassman, Miriam Temin and a team at the Center for Global Development, are so important. They provide us with specific examples of global health success that they culled from more than 300 examples of rigorous impact evaluations, and explain why they were successful.

“Around the world, people are benefiting from a global health revolution,” wrote Glassman and Rachel Silverman, both of the CGD, in a blog of the British Medical Journal (BMJ). “More infants are surviving their first months of life; more children are growing and thriving; and more adults are living longer and healthier lives. This amazing worldwide transformation begs several questions: What, specifically, are we doing right? What are the policies and programs driving the global health revolution from the ground up? Or put more simply, what works in global health, and how do we know?”

Those are the questions the authors set out to answer in this, the third version of “Millions Saved.” The first, published in 2004, provided 17 large scale global health successes. In 2007, the second edition updated the original 17 cases, and added three new ones. The 2016 version profiles 22 cases – 18 success stories and four cases of promising interventions that could not maintain success when scaled up. No one likes to talk about their failures and disappointments, but much can be learned from them.

The authors have provided us with an amazing variety of health interventions ranging from disease-specific areas like HIV, malaria, meningitis, diarrhea, polio and cancer to broader programs like neonatal, child, maternal and family health, and cash transfers, pay-for-performance and universal health care. As well as tobacco control and road safety. Africa and Asia each had seven case studies and four came from Latin America and the Caribbean.

I was disappointed that the authors could not find any successes in family planning, as the first two editions had. They addressed this in the BMJ blog:

“We are often asked about why the new Millions Saved omits a favored intervention, disease priority, or specialty. Where is mental health, for example? Or heart disease? Cancer? And what about tuberculosis or family planning? The answer is always the same: despite our best efforts, we could not find a suitable, rigorous evaluation of an at-scale program that demonstrated attributable health impact. That is not to say that interventions in these areas have not improved health at scale – it is quite likely that they have. But without rigorous at-scale evaluation, we simply cannot and do not know for sure.”

Dr. Duff Gillespie, professor at the Bill & Melinda Gates Institute for Population and Reproductive Health at the Johns Hopkins Bloomberg School of Public Health, agrees there have been few well controlled intervention studies that measure the impact of family planning and suspects this will not change because donors do not see the need for such studies and because most researchers do not find such studies necessary.

“Why? There is a wealth of evidence documenting the use-effectiveness of contraceptives in preventing pregnancies. There is also tons of evidence that shows contraceptive use increases with access to family planning services. Lastly, the correlation between contraceptive use and reductions in maternal and child mortality is one of the strongest in public health. Are such correlations causal? In the case of reductions in the maternal mortality rate, absolutely. Since women must be pregnant to become a maternal death, any intervention that is effective in reducing the number of pregnancies will result in a reducing of maternal deaths. This is where contraceptive use has its biggest impact.”

Kim Longfield, director of Strategic Research and Evaluation at Population Services International (PSI), says her team did a systematic review of the effectiveness of social marketing in family planning and found a study of one program that was at scale and had significant impact – “A randomized community trial of enhanced family planning outreach in Rakai, Uganda,” which was published in Studies in Family Planning in March 2010.

The prevalence of pregnancy decreased by 3.1% in the intervention group (from 16.6% to 13.5%) and 1.3% in the control group (from 18.1% to 16.8%) between baseline and follow-up three years later. Longfield said this difference was “statistically significant.”

Longfield also said that rigorous evaluations of at-scale programs are “incredibly difficult to carry out on programs at scale. Imagine trying to have control groups at a national level.”

Steven Chapman, evidence, measurement and evaluation director of the Children’s Investment Fund Foundation in London, says that there is already ample evidence of family planning causing a decline in fertility, child mortality and maternal morbidity and mortality without trying to prove it as rigorously as is required by the “Millions Saved” case studies.

“Amanda encourages us to do a rigorous study to prove the connection but I think it is unnecessary – the health benefits of family planning are one of the many quantifiable benefits of it, and we can’t count the non-quantifiable ones.”

I hope to see this series continue into the future, perhaps with a family planning success the next time. Indeed, Glassman and Silverman end their BMJ blog with a plea: “If you care about cancer or heart disease, or tuberculosis, or family planning, please help us include it in the next “Millions Saved.”

Summaries of the twelve of the 18 success stories documented in “Millions Saved” can be found here, on the CGD website. A hard copy of the book can be ordered here.

Lesson_MillionsSaved_0516BlogLg

In West Africa, More People Using Family Planning but Millions Not Treated for HIV

26th Apr 2016

National Family Planning Campaign

People gather for the Bamako launch of the national family planning campaign in Mali earlier this month. Only 9.9% of married women use modern contraception, according to the 2012-2013 Demographic and Health Survey. Photo: David J. Olson

By David J. Olson

BAMAKO, Mali Last year, there were several reports of how West Africa, after decades of seriously lagging behind the rest of the world (and Africa) in family planning, was finally starting to embrace it. IntraHealth International covered this topic extensively on its Vital blog, and I wrote about my own views of family planning in Mali here at Global Health TV.

Senegal, in particular, emerged as a family planning leader in West Africa and provided hope for the rest of the region. The three main reasons for Senegal’s success were strong political will, better coordination and collaboration and innovative approaches, according to Babacar Gueye, IntraHealth country director in Senegal.

New programs here in Mali, like Keneya Jemu Kan (USAID Communications et Promotion de la Santé, in the Bambara language), are making a major push to increase health indicators beyond the anemic progress of the past three decades. For example, the percentage of married women using any modern method of family planning in Mali has only increased from 1.3% in 1987 to 9.9% in 2013, and Keneya Jemu Kan is working to bend that rate upwards. (Full disclosure: I work as a consultant for Keneya Jemu Kan).

But a disturbing new report from Médecins Sans Frontières (MSF), or Doctors Without Borders, claims that similar progress is not being made in HIV/AIDS. On the contrary, MSF claims that millions of people in West and Central Africa are being left out of the global HIV response despite globally agreed goals to curb HIV by 2020, and is calling on the international community to develop and implement an urgent plan to scale up antiretroviral treatment for countries where critical medicines reach fewer than one-third of the population in need.

The 25 countries that make up West and Central Africa account for one in five new HIV infections globally, one in four AIDS-related deaths and nearly half of all children born with HIV. MSF points out that the region has a low HIV prevalence, with 2.3% of the population infected with HIV, but that is three times the worldwide prevalence of 0.8%, and pockets of the region have prevalence over 5%.

HIV prevalence in West and Central Africa is lower than Eastern and Southern Africa. This lower prevalence has led to “poor knowledge of the disease among the general population, political leaders and health workers” and less funding by international donors.

“The converging trend of international agencies to focus on high-burden countries and HIV hotspots in sub-Saharan Africa risks overlooking the importance of closing the treatment gap in regions with low antiretroviral coverage, said Dr. Eric Goemaere, MSF’s HIV referent. “The continuous neglect of the region is a tragic, strategic mistake. Leaving the virus unchecked to do its deadly work in West and Central Africa jeopardizes the goal of curbing HIV/AIDS worldwide.”

Pape Gaye, president and CEO of IntraHealth and a native of Senegal, says that the problems cited by MSF are another example of why the international community needs to mobilize to help countries strengthen their health systems.

“The difficulties experienced by Ebola-affected countries to address the disease and the inabilities of countries to protect and sustain gains, including recent ones in family planning and reproductive health, point to the need for more attention to health systems strengthening,” said Gaye. “The region of West and Central Africa is poised to enter a new era of growth and prosperity but the momentum will dramatically slow down or vanish unless coordinated effort is made to rid the region of HIV/AIDS. This is not the time to continue erratic and fragmented interventions which produce results such as those described in the MSF report.”

The Ouagadougou Partnership, an initiative of nine French-speaking West African countries to promote family planning started in 2011, set a goal of reaching one million new family planning users in these nine historically under-performing countries by 2015. At their annual meeting in December 2015, members of the Partnership celebrated the achievement of this goal.

MSF is now calling for the same kind of urgent call to arms to address HIV/AIDS and a plan to achieve progress, much as the Ouagadougou Partnership did to address family planning. If we can do it for family planning, we should be able to do it for HIV/AIDS and thereby ensure that West and Central Africa do not thwart our efforts to achieve an AIDS-free generation.

Facing the greatest humanitarian crisis of our lifetime

23rd May 2016

Right now in Istanbul, the World Health Organization (WHO) is convening the first ever humanitarian summit to address the current human suffering that is happening now all over the world. The summit will call on global leaders and organizations to discuss key priorities and areas to tackle what has been described as the greatest humanitarian crisis of our lifetime.  One key theme high on the agenda is conflict and displacement of people, something the country Lebanon knows only too well.

With a population of only 4 million people, Lebanon, sits in the Middle East between Syria and Israel.  Despite its small population, the country has the largest number of refugees per capita in the world. It’s estimated that Lebanon currently has over 1.5 million refugees, with more arriving every day.

In an exclusive Global Health TV film report, we travelled to Bekka Valley in Lebanon where 700,000 refugees are currently living in temporary settlements and tents.

Speaking with Hajar, a mother of four, who fled her home town of Al Kusayr with her children, after her husband went missing during heavy shelling, said ‘We were living in our own house now we are living in a tent… our life here has its effects on the children, it reflects on their faces.

On the ground, World Vision is one of six agencies that make up the Lebanon Cash Consortium (LCC) providing cash assistance to Syrian refugees. Enabling them to buy items fundamental to their survival, such as clean water, food, medicine and shelter. Refugees are issued with a debit card which they can use at any ATM on a monthly basis.

In the film, Hajar said “the LCC gave me 260 card, I can pay the land’s rent from it and the electricity bill. They give me also the nutrition card so I can get the nutrition needed for my family.”

International agencies are also fighting to prevent a lost generation of children.  Refugee children struggle to access education because of distances and transport costs. With the cash assistance from the LCC, families are able use some of the money to send their children to school.

Despite the overwhelming number of refugees in Lebanon, a report released by the European Commission’s Humanitarian aid and Civil Protection department (ECHO) and UK AID shows the LCC model of assistance has been affective way to reduce vulnerability of refugees. The report also states that refugees who receive LCC assistance are four times happier than those that don’t – feeling empowered to meet the variety of needs for themselves and their families with dignity.

Watch the full story of Hajar and the situation in Lebanon here or in the video above.

Brazil Struggles to Contain Damage of Deadly Mosquito

31st Mar 2016

By David J. Olson

RIO DE JANEIRO, Brazil A group of about 20 poor parents (mostly women) from the slums gathered this month in the offices of Saúde Criança (“child health” in Portuguese), a social enterprise that works with impoverished children and their families in a holistic way. After a meditation, they got down to the main point of the meeting the Zika virus and how to avoid it.

These poor young mothers are prime candidates for Zika. Aedes aegypti, the mosquito that transmits Zika, will suck anyone’s blood rich or poor. But they thrive in the densely populated favelas of Rio and other Brazilian cities where few people have screened windows and where even mosquito repellant may be a luxury. Many people have water cisterns on their roofs, usually not covered, which makes an ideal breeding ground for Aedes aegypti.

Dr. Sylvia Lordello, a medical doctor on staff at Saúde Criança, told the parents that prevention starts at home and reviewed a series of steps that could be taken to make their homes less hospitable to mosquitoes, such as covering their cisterns and not leaving water in the plates under house plants.

“If the whole country fights Zika, the mosquito cannot win,” Dr. Lordello told the parents. “Zika is not stronger than the country.”

That is the key message of the national campaign against Aedes aegypti: “A mosquito is not stronger than an entire country,” with the hashtag #ZIKAZERO. In a video on the #ZIKAZERO campaign website, you can see some of the strategies the government is promoting against Zika.

The government's key message on Zika: "A mosquito is not stronger than an entire country."

The government’s key message on Zika: “A mosquito is not stronger than an entire country.”

Aedes aegypti is, in fact, one of the most highly efficient disease machines ever created. It bites aggressively during the daytime, so bed nets are not effective against it. It often bites four or five people during one meal. Its bite is painless so people don’t always know it’s there, and so do not swat and kill it. It thrives in dense, urban environments. Aedes aegypti is the main vector not only for Zika but also dengue, Chikungunya and yellow fever (which was eradicated in urban Brazil years ago). All of this, and more, make it a formidable foe.

Brazil is the country most affected by Zika. It was diagnosed here in May 2015. The Brazilian Ministry of Health estimates that there were 0.4 to 1.3 million cases of Zika virus infection in 2015, mostly in the hot, poor northeast.

The symptoms of Zika are normally mild – much milder than dengue – and it might be considered a minor nuisance except that Zika is suspected of being linked to microcephaly, a condition in which babies are born with a smaller head and brain abnormalities. In adults, Zika has been associated with Guillain-Barré syndrome, that can result in paralysis and even death. These links are strongly suspected but have not been scientifically confirmed.

As of March 19, Brazil has reported a total of 6,671 cases of microcephaly and/or central nervous system malformation (not all caused by Zika), according to the World Health Organization (WHO). This is a huge increase from an average of 163 cases reported annually from 2001 to 2014. Of these, 907 have been confirmed for the Zika virus. Microcephaly has been detected throughout Brazil but the recent increase is concentrated in the Northeast.

The WHO said that it expects Brazil will have more than 2,500 babies born with microcephaly from Zika if current trends continue.

Brazilian federal and state governments and scientific agencies are mobilizing against the Zika virus, like the #ZIKAZERO campaign. The Lancet has urged this strategic plan for governmental action. Last week, Brazil’s National Development Bank announced it will provide $136.6 million to fight Aedes aegypti.

The military has been playing a major role. In February, 200,000 Brazilian soldiers were mobilized across the country to raise awareness about the the mosquito that spreads the Zika virus. The aim was to reach 3 million families in a single day, with soldiers visiting homes, parks and shopping malls in 350 cities.

Churches are also getting involved. The Brazilian Seventh Day Adventist Church is leading a national campaign to eradicate Zika. The church’s Zika Project started in February with a public awareness drive involving 200,000 students and hopes to expand to at least 600,000 members of the church.

Zika is raising issues about whether contraception and even abortion should play a role in helping prevent babies with microcephaly. This can be controversial given that many of the Zika countries are heavily Catholic.

Dr. Sylvia Lordello, doctor at Saúde Criança in Rio de Janeiro, talks  about how to prevent Zika. Photo: David J. Olson

Dr. Sylvia Lordello, doctor at Saúde Criança in Rio de Janeiro, talks about how to prevent Zika. Photo: David J. Olson

Saúde Criança has always promoted family planning among the families in its program through regular condom distribution and lectures on family planning. And they believe this strategy is working because only seven out of the 600 women in their Rio de Janeiro program are pregnant at the present time, according to Cristiana Velloso, executive director of Saúde Criança.

This contraception might also help prevent cases of microcephaly.

“What we can do here is talk to our families about Zika, give them insect repellant (S.C. Johnson & Son, maker of Off! and Raid, just donated 25,000 bottles to Saúde Criança) and tell them how they can prevent Zika,” said Velloso. “We can’t do much more, and even the government can’t do much more.”

Faith Community Steps Up Its Commitment To Family Planning

23rd Feb 2016

By David J. Olson

NUSA DUA, BALI, Indonesia To some, it may have been an incongruous image twelve faith leaders, representing all the major religions of the world, standing on the stage at the closing ceremony of the International Conference on Family Planning (ICFP) here.

12 faith leaders at the closing ceremony of the International Conference on Family Planning in Indonesia last month, during the reading of the commitment of a larger group of 85 faith leaders who attended the conference. Photo courtesy of International Conference on Family Planning.

Faith leaders at the International Conference on Family Planning in Indonesia, during the reading of the commitment of a larger group of 85 faith leaders who attended. Photo courtesy of International Conference on Family Planning.

After all, everyone knows that most religious leaders are against family planning, right? That was never true, and now it’s becoming even less true. The twelve leaders represented 85 religious leaders and representatives of faith-based organizations (FBOs) who came to Bali from 26 different countries to discuss best practices and scaling up services to help families achieve what they like to call “the healthy timing and spacing of births” during a two-day Faith Pre-Conference.

It might surprise some to know that this support is not just for natural family planning, but extends to all forms of modern contraception with the single exception of sterilization, which is not approved by all types of Islam. All other modern methods are acceptable to all the religions represented at ICFP Buddhist, Christian, Confucian, Hindu, Jewish and Muslim.

“Biblically speaking, family planning is supported because it helps provide life in its fullest,” said Dr. Tonny Tomwesigye, executive director of Uganda Protestant Medical Bureau. “If you have 100 children who are miserable, you have made the world a worse place. If you have the number of children you can successfully educate and who can enjoy good health and fulfill their potential, you are making the world a better place.”

Leaders of all these religions, including Islam, point out that there is nothing in their belief systems that raises objections to family planning.

In fact, there were many traditional Islamic leaders at the Faith Pre-Conference. I sought out one that I thought might be more conservative on such issues, Sheikh Mangala Luaba, Grand Mufti and president of the Union of Muslim Councils for East, Central and Southern Africa, making him one of the most senior Islamic leaders in sub-Saharan Africa.

He said the Quran permits two types of family planning natural methods such as abstinence and “the scientific, modern methods involving medication. Reversible methods are allowed. Permanent methods are forbidden. Different methods are promoted, depending on the situation.”

The 85 representatives hammered out their statement of commitment to family planning that was read in the closing ceremony by Rev. Cannon Grace Kaiso, general secretary of the Council of Anglican Provinces of Africa (you can see the faith community’s appearance on stage 15 minutes into this video).

The statement cited their “commitment to continuing to inform and educate our communities on family planning, especially youth and faith leaders, as is consistent with our faith values as it protects the lives and health of mothers, children and families.”

The statement also re-affirmed “our commitment to continuing to provide and support quality family planning service delivery, referrals and products to all communities.”

Dr. Douglas Huber, reproductive health specialist and co-chair of the Reproductive Health/Family Planning Working Group of Christian Connections for International Health, said that the visible and active participation of faith leaders at this conference was much greater than in the first three family conferences that started in 2009.

“We experienced a groundswell of interest and support for planning and participating in the Faith Pre-Conference and for the faith presence at the full conference, including the unique commitment statement by faith leaders at the final plenary,” said Huber. “This bodes well for new and larger partnerships with the faith community.  We find this very exciting.”

That is not to say that FBOs are perfect in their implementation of family planning.

Some faith leaders freely admitted that they need to do a better job of documenting their family planning work and providing an evidence base that can be used to improve the quality of their work. However, this same point was also made about secular family planning work in the larger conference.

In terms of quality of counseling, FBOs generally lag behind facilities of other managing authorities, said Janine Barden-O’Fallon of MEASURE Evaluation, in a presentation based on a study in Haiti, Kenya and Malawi (though Haitian FBO facilities perform better than public sector facilities). Availability of FP services in FBOs, varies by country (57% offer FP services in Malawi compared to 89% in Haiti). Generally, availability in FBOs lags behind facilities of other managing authorities.

However, in her conclusion, Ms. Barden-O’Fallon said: “FBOs are well-positioned to contribute to successful family planning efforts.” Volunteerism and free choice need to be upheld in all programs, she said. Method availability and counseling are key.

Enthusiasm for FBOs to contribute more to the global family planning efforts was certainly evident among these 85 faith leaders.

“In achieving the Sustainability Development Goals, we can’t afford to sideline the FBOs,” said Karen Sichinga, executive director of Churches Health Association of Zambia. “In some African countries, we (FBOs) provide 70% of all health care. We won’t achieve the SDGs without FBOs.”

Here’s a summary of the faith community’s presence at the International Conference on Family Planning in Nusa Dua, Bali, Indonesia on the website of Christian Connections for International Health, one of the sponsors of the Faith Pre-Conference.

 

Can Polio and Guinea Worm Both Be Eliminated in 2016?

14th Jan 2016

By David J. Olson

Only once in history has a human disease has been eliminated from the face of the earth. That was smallpox, eradicated in 1980.

There is a reasonable chance that in 2016 two diseases could be eliminated  polio and guinea worm.

We won’t eradicate either disease this year. Eradication requires that several years pass with no new cases being detected. But it does look like 2016 is the year we could eliminate both diseases.

To be sure, we have been close before with polio, and then lost ground. The World Health Organization (WHO) says that “failure to stop polio in these last remaining areas could result in as many as 200,000 new cases every year, within 10 years, all over the world.” So there is little room for error.

Polio

Polio cases have decreased by over 99% since the WHO’s Global Polio Eradication Initiative was launched in 1988, from an estimated 350,000 cases that year to 51 cases in Pakistan and 19 in Afghanistan in 2015 a mere 70 cases.

Sona Bari, WHO spokesperson for the Global Polio Eradication Initiative, said our chances of eliminating polio in 2016 are better than ever before.

Pakistan and Afghanistan have come up with innovative ways to reach the children who are most vulnerable, whether living in remote locations, in under-served communities or even in conflict zones,” she said. “For example, vaccinators from the community vaccinate their neighbors rather than coming in from other communities during a time-bound vaccination drive. Or when there is a pause in conflict, vaccination teams will go in and vaccinate an area. Most importantly, the people and the government in both countries are committed to eradicating polio, sometimes going to extraordinary lengths to fulfill their duties.”

The campaign to eliminate polio has already gone on longer than the campaign to eliminate smallpox. The progress has been slow and steady, with numerous setbacks. In 1994, WHO declared the Americas region free of polio, followed by the Western Pacific region in 2000, the European region in 2002 and the Southeast Asia region (including India) in 2014.

On July 24, 2015, Nigeria marked one full year without a single new case of locally acquired polio, ending polio’s reign of terror in Africa and prompting Bill Gates to declare a polio-free Africa as the number one “good news story of 2015.”

Is 2016 the year polio will be eliminated, a National Geographic blog asks? “I’m going to be an optimist and say the big public health story of 2016 will be the last case of polio in the world,” Dr. William Moss, head of epidemiology at the International Vaccine Access Center at Johns Hopkins University, told National Public Radio.

 

Guinea Worm

Credit: The Carter Center

Nuru Ziblim, a Guinea worm health volunteer in Ghana, educates children on how to use pipe filters to avoid the parasite when they go to the fields with their families. Credit: The Carter Center

 

Polio may have to share that honor with Guinea worm. The Carter Center, which has led the international campaign to eradicate the disease since 1986, announced on Jan. 7 that only 22 people still had Guinea worm in 2015, and those cases were in 20 endemic villages in Chad (9 cases), Mali (5), South Sudan (5) and Ethiopia (3).

The Carter Center told me they are keeping their fingers crossed that these cases in 2015 were some of the last. If Guinea worm is eradicated, it would be the first parasitic disease eradicated and the first disease eradicated without the use of a vaccine or medicine.

In 1986, when the Carter Center started this campaign, there were an estimated 3.5 million Guinea worm cases occurring in 21 countries in Africa and Asia.

“Guinea worm reductions in South Sudan and Mali in 2015 are even more remarkable because both countries have significant insecurity or civil unrest and had the largest number of cases in 2014,” said Dr. Ernesto Ruiz-Tiben, director of the Carter Center’s Guinea Worm Eradication Program. “For these nations to make this much progress against disease under such dire circumstances is heroic by any measure.”

“As we get closer to zero, each case takes on increasing importance,” said former U.S. President Jimmy Carter. “Full surveillance must continue in the few remaining endemic nations and neighboring countries until no cases remain to ensure the disease does not return. The Carter Center and our partners are committed to seeing that this horrible parasitic disease never afflicts future generations.”

“I would like to see Guinea worm completely eradicated before I die I’d like the last Guinea worm to die before I do,” said President Carter, recently diagnosed with cancer, in August.

With President Carter now in remission and the last Guinea worm possibly being exterminated in 2016, it looks like he may get his wish.

So it’s a race to the finish line between polio and Guinea worm. Conquering just one of these would be a major accomplishment. If we get both, 2016 will go down as one of the most significant years in global health history.

The Biggest Global Health Stories of 2015, and One Untold Story

17th Dec 2015

By David J. Olson

There seemed to be a lot of good global health news in 2015, especially when compared to 2014, when Ebola was ravaging West Africa and scaring the rest of the world. In the last 12 months, Ebola has mostly passed, progress was made against malaria and AIDS and the climate deal in Paris raised hopes that less climate change could improve global health.  Here are what I consider some of the top global health stories of the year, not necessarily in order of priority:

Ebola on the Decline: A year ago, Ebola was raging. As of Dec. 16, there have been 11,315 deaths and 28,640 cases of Ebola. But Ebola has not disappeared entirely. It re-emerged in Liberia after having earlier been declared Ebola-free. Dr. David Nabarro, the UN special envoy on Ebola, said that he expects transmission in Guinea to finish before the end of 2015 and in Liberia in early 2016. Here’s an update on Ebola in an interview with Dr. Nabarro.

Climate Change Emerges as Health Issue: It is increasingly obvious that climate change is becoming the central development issue of our time. It is also a major obstacle to global health. A Journal of the American Medical Association study explained how climate change adversely affects human health, including decreased respiratory health, increases in infectious diseases, decreased food security and more mental stress. A report produced by a commission of The Lancet and University College London went further to state that climate change threatens to undermine 50 years of global health progress but, at the same time, presents the greatest global opportunity to improve people’s health. “The Paris Accord just signed is monumental in their potential to protect the health of my one-year old grandson Troy and all future generations,” said Ray Martin, long-time health officer at the U.S. Agency for International Development and executive director emeritus of Christian Connections for International Health.

Continued Progress on Malaria: In 2015, the WHO declared that the Millennium Development Goal on malaria had been met “convincingly.” The Economist declared that “the end is in sight for one of humanity’s deadliest plagues” and that Swaziland is on the brink of becoming the first malaria-free country in sub-Saharan Africa. In fact, Bill Gates says that malaria could be eradicated by 2040 even without a vaccine.  Last week, the WHO released its annual World Malaria Report and reported a significant increase in the number of countries moving towards malaria elimination but with slower progress reported in Africa, which accounts for 88% of all malaria cases in the world.

Tipping Point for AIDS Proves Elusive: Last year in this space, I wrote that “we had reached the long anticipated tipping point of AIDS” – the point where more people were on AIDS treatment than the number of new infections. I wrote that based on the ONE Campaign’s “At the Tipping Point: Tracking Global Commitments on AIDS” report which was based on UNAIDS data. It now turns out that this conclusion was premature. In this year’s report, “Unfinished Business,” ONE reports that “newly remodeled estimates of the data for 2013 suggest that the world had not reached the tipping point in 2013.” Erin Hohlfelder, head of global health policy at the ONE Campaign, explained that UNAIDS revised past years’ treatment and infection projections based on better data and a revised mathematical model. However, we are tantalizingly close to the tipping point (see the graph on Page 6 of that report to see how close). The good news is that UNAIDS estimated that seven times as many people were accessing antiretroviral therapy by 2015 as had been the case in 2005 and that AIDS-related deaths have fallen by 42% since the 2004 peak.

Global Health in the Sustainability Development Goals (SDGs): On Dec. 31, the SDGs replace the Millennium Development Goals as the planet’s major way of measuring development progress. Health was very prominent in the MDGs, accounting for three of the seven MDGs. Global health is much less prominent in the SDGs (they account for only one of the 17 goals) but the SDGs cover some critical areas of global health totally ignored by the MDGs, such as non-communicable disease, substance abuse and traffic accidents. Linda Fried of Columbia University makes the case that the SDGs “offer a broader framework to address public health concerns in a more holistic way.” In a report released last week, the WHO looked back at the trends and positive forces during the MDG era and assesses the main challenges that will affect health in the next 15 years. See my September blog here on Global Health TV for more on global health and the SDGs.

Africa Defeats Meningitis: Did anyone notice that Africa wiped out meningitis between 2010 and 2015 due to a mass vaccination campaign? As recently as 1997, meningitis infected more than a quarter million people and killed 25,000 in the “meningitis belt” that stretches from Gambia to Ethiopia. But after the vaccination campaign, the number of cases dropped from 1,994 in 2009 to four in 2013. “The disease has virtually disappeared from this part of the world,” said Dr. Maire-Pierre Preziosi of the World Health Organization. But meningitis could return and the vaccination efforts must continue.

More Progress on Contraception:  The world came a bit closer to its goal of reaching 120 million additional girls and women with modern contraception by 2020. In its annual progress report, FP2020 reported that the number had increased by 24.4 million since 2012. This is good news but even FP2020 admitted that “the report shows that FP2020 and its partners must take immediate action to speed up progress.” Amanda Glassman, director of global health policy of the Center for Global Development, says this is the right time for a fresh look at family planning efforts. “2016 is the midpoint of the FP2020 initiative and revisits of performance projections, funding requirements, allocation practices and incentives for alignment of effort could have an impact,” she wrote.

Mass Famine Plummets: Here’s another underreported story: Hunger has fallen 27% since 2000, according to the 2015 Global Hunger Index. However, the same report found that the state of hunger is still serious or alarming in 52 countries. Thanks to NPR’s Goats and Soda Blog for bringing this underreported piece of good news to my attention.

Surging Global Health Funding Stabilizes: During the era of the Millennium Development Goals (2000-2014), $228 billion was allocated to address the three health-related MDGs. Spending grew rapidly in the first ten years, but it was stagnant from 2010 to 2014, and actually decreased by 1.6% between 2013 and 2014, according to Financing Global Health 2014 published by the Institute for Health Metrics and Evaluation. Here’s a great visual aid for understanding the trends in global health spending since 2002. The report noted that low- and middle-income countries themselves greatly increased their spending, which reached an all-time high of $711 billion in 2012.

And finally, here’s a global health issue that wasn’t a major story but should have been:

Untold Global Health Story of 2015: Earlier this year, the Johns Hopkins University Bloomberg School of Public Health and the Consortium of Universities for Global Health announced a contest for diseases and issues that impact global health but receive little or no attention from the mainstream media. After receiving 170 nominations, they chose mycetoma, a flesh-eating, bone-destroying disease that has spread misery for centuries and commissioned a three-part series called “The Most Neglected Disease.”

Diabetes, Killing 5 Million A Year, Becomes Major Menace to Global Health

23rd Nov 2015

By David J. Olson

Over the last 25 years, diabetes has emerged as a major threat – and growing consumer of precious global health resources – in the developing world. In 1990, according to the Institute for Health Metrics and Evaluation (IHME), it was not even in the top ten leading causes of death globally.  Now it is number nine on the list.

In the seventh edition of its Diabetes Atlas, the International Diabetes Federation (IDF), an umbrella organization of over 240 national diabetes associations, says that diabetes kills almost 5 million people every year and that every six seconds a person dies from diabetes. This compares to those who die each year from AIDS (1.5 million), tuberculosis (1.5 million) and malaria (600,000).

The latest version of the Diabetes Atlas, which will be published on Dec. 1, calls diabetes “one of the largest global health emergencies of the 21st century.” Currently, 415 million people have it (1 in 11). By 2040, if current trends continue, 642 million will have it (1 in 10).

Like other non-communicable diseases, an estimated three quarters of people with diabetes live in low- and middle-income countries. Often the disease hits people of working age, in their most productive years. In most sub-Saharan African countries 60% or more of adults with diabetes die before the age of 60.

IDF expects to see a sharp increase in diabetes in low- and middle-income countries by 2040, such as South and Central America where it expects an increase of 65%.

World Diabetes Day was marked on the 14th of November with a focus on healthy eating and the slogan “Halt the diabetes epidemic: Make healthy eating a right, not a privilege.” IDF calls for action to improve access and affordability of healthy food choices to reduce the burden of diabetes and save billions in lost productivity and healthcare costs.

IDF healthy eating recommendations to reduce diabetes

IDF healthy eating facts

Already, 12% of global health expenditures is being spent on diabetes ($673 billion), according to the IDF.  This year, diabetes will cost somewhere between US $673 and 1,197 billion in healthcare spending.

The costs associated with diabetes include the financial burden placed on individuals and their families due to the cost of insulin and other medicines as well as the increased use of health services, loss of productivity and disability. So diabetes is not only a health issue but a serious obstacle to sustainable economic development.

And here’s one thing that diabetes has in common HIV – many people who have it don’t know they have it. The IDF estimates that 46.5% of adults with diabetes worldwide are undiagnosed. The African region has the highest level of undiagnosed diabetes – more than two-thirds of Africans (66.7%) who have diabetes are unaware they have it. But other regions also have high levels of undiagnosed diabetes – South Asia (52%), Middle East and North Africa (41%) and Latin America (39%). Even in high-income countries, about 36% of people with diabetes are undiagnosed. Of course, the earlier a person is diagnosed and management is initiated, the better the chances of preventing harmful and costly complications.

Modern lifestyle behaviors associated with urbanization are responsible for the growth of diabetes, including processed foods (with high fat content, sugar-sweetened beverages and refined carbohydrates) and physical inactivity and long sedentary periods. These behaviors are associated with increased risk of obesity and type 2 diabetes (which accounts for the vast majority of diabetes).

“However, in order to meet the 2025 target of no increase in diabetes, much more needs to be done,” says the seventh edition of Diabetes Atlas. “ Whole populations must change their lifestyle behaviors by modifying diet and increasing physical activity levels. To support this, IDF has reviewed the evidence on which types of food predispose to type 2 diabetes and has released nine recommendations for a healthy diet for the general population (see box).

To combat this, IDF is calling on governments to improve education on the diagnosis and management of all types of diabetes, public health education to encourage behavior change and to take preventive action by taxing unhealthy foods starting with sugar-sweetened beverages, such as soft drinks. In 2015, IDF published its Framework for Action on Sugar, which recognizes the important role that excess sugar consumption has in increasing the risk of type 2 diabetes and presents policy initiatives aimed at reducing consumption of sugar and shifting to healthier foods.

In India, where more than 1 million people die of diabetes annually, Arogya World, a U.S. non-profit organization working to prevent NCDs, provides a tangible example of what can be done to combat diabetes. Earlier this month, Arogya World launched a new chronic disease prevention mobile app called “MyArogya” for working Indians. MyArogya has content on diabetes, heart disease, stroke and kidney disease, as well as food and activity trackers to help people make healthy lifestyle changes. Future plans include a smoking cessation program and healthy recipe videos among other features meant to appeal to working Indians.

“I think mHealth is a really smart solution to address NCDs in India where cell phones are so prevalent,” said Nalini Saligram, founder and CEO of Arogya World. Saligram says she hopes the app, funded by the Cigna Foundation, reaches 1 million working Indians in a few years.

Saligram said mDiabetes, an earlier text messaging program started in India in 2012, was successful in reaching a million people and showing positive health behaviors. Building on that success, Arogya World developed MyArogya, which has more content and will be better able to monitor health behavior.

On Dec. 1, the IDF will release the seventh edition of the Diabetes Atlas on this website.

A Global Health TV interview explains how the U.S. is winning the battle but losing the war in the fight against type 2 diabetes.

Diarrhea Deaths Are Falling But ORS Use Still Stagnant

26th Oct 2015

By David J. Olson

I’m grateful to Chelsea Clinton for her admission that she is “obsessed with diarrhea,” and her total lack of embarrassment in bringing it up repeatedly. In an interview with Fast Company, it was the first thing she wanted to talk about.

I’m grateful to her because she is, as far, as I know, the only well-known public figure to champion the prevention and treatment of diarrhea, the world’s second biggest killer of children under five years old, even though we have cheap and effective ways of dealing with it.

“It’s completely unacceptable that more than 750,000 children die every year because of severe dehydration due to diarrhea,” said Clinton last year. “I just think that’s unconscionable.”

We need more champions of the diarrhea issue.

Four years ago, I wrote a blog bemoaning the fact that oral rehydration therapy (ORT) seemed to be on life support, even though The Lancet once called it “the most important medical advance of the 20th century.” ORT and its practical application, oral rehydration solution (ORS), have long been found to be both effective and cost-effective in treating the dehydration caused by diarrhea.

Bangladesh is perhaps the best example of a country that has made stellar progress in fighting diarrhea through ORS. The treatment of diarrhea increased from 58% in 1993 to 81% in 2011.  Productive collaborations between the government, the private sector and organizations like the Social Marketing Company, which used social marketing revenues to build an ORS factory in Bangladesh in 2004, have led to tremendous improvements in diarrhea disease management.

Starting in the 1970s, ORS has saved an estimated 50 million lives, costing less than $0.30 per sachet, according to the WHO. In 1978, the World Health Organization (WHO) established the Control of Diarrheal Diseases Program, and by the early 1980s, most developing countries had their own dedicated national programs.

But even though ORS was cheap and effective, the global health community moved on to other diseases, like AIDS and malaria. In the 1990s, these diarrheal disease programs were merged into broader child health programming, and lost their dedicated funding, staff, and systems. A 2008 analysis that looked at changes in ORS use in children under three found declines in 23 countries and increases in only 11.

A 2009 research study conducted by PATH, a leading NGO working to fight diarrhea, to evaluate the funding and policy landscape found that “diarrheal disease ranked last among a list of other global health issues.”

After years of neglect, diarrhea is back on the global health map. Diarrhea deaths among children under five are down from 700,000 per year in 2011 to around 531,000 in 2015, according to PATH, a drop of 24% in four years. The bad news is that ORS use has stagnated, says PATH, at around 35% over the last 10-15 years.

Why has diarrhea death dropped even though ORS has stagnated?

“It’s been because of increasing access to a set of protection, prevention and treatment interventions,” said Ashley Latimer, senior policy and advocacy officer at PATH. “More children are being vaccinated against rotavirus (a leading cause of diarrhea). Understanding the importance of hand-washing and clean drinking water is improving. Improved nutrition and exclusive breastfeeding probably plays a small role.”

In 2013, the WHO and UNICEF published “Ending Preventable Child Deaths from Pneumonia and Diarrhoea by 2025,” the first-ever global plan to tackle the two diseases that take the lives of 2 million children every year, which was supported by more than 100 nongovernmental organizations.

There are several efforts underway to fight diarrhea more effectively.

For example, PATH is working to improve the formulation of ORS to make its benefits more apparent to caregivers.

Rehydration salts for Diarrhea

A mother administered oral rehydration salts to her child in Kenya. Credit: PATH/Tony Karumba

“Reimagining global health” recently highlighted “30 high-impact innovations to save lives.” One of them (see Page 17) included several new treatments to reduce the burden of severe diarrhea, such as DiaResQ, which supplements the use of ORS and provides nutrients for intestinal repair.

An already established innovation is to create “comprehensive diarrhea treatment” by combining zinc with ORS. Zinc is a vital micronutrient that helps the body absorb water and electrolytes, reduces the duration and severity of diarrhea and prevents subsequent infections in the two to three months following treatment. Diarrhea mortality is reduced by 23% when zinc is administered with ORS. Unfortunately, use of zinc is even worse than ORS – only 5% as compared to 35% for ORS.

Diarrheal disease research and development funding is increasing modestly. In 2013, it was $200 million, up from $170 million in 2012. As in previous years, the top three funders accounted for almost three-quarters of total funding – the Bill & Melinda Gates Foundation (25% of funding), the U.S. National Institutes of Health (23%) and industry (22%).

“With the introduction of rotavirus vaccines and advances in WASH interventions, these are exciting times,” said Deborah Kidd, senior communications officer at PATH. “However, what is often overlooked is the burden of diarrhea morbidity among children in the developing world. Chronic, repeated infections, resulting malnutrition and stunted development, and the persistent economic burden on the family all contribute to a destructive cycle that keeps families in poverty. So it’s great news that deaths are declining, but that the problem of childhood diarrhea and its long-term consequences are far from solved.”

UNICEF reports that improvements in drinking water, sanitation and hygiene are reducing diarrheal disease (90% of the world’s population use improved drinking water sources and two-thirds use improve sanitation facilities).

However, the decline in diarrhea deaths should be no cause for complacency: UNICEF also reports that when children do fall ill with diarrhea, only two in five children receive appropriate treatment, including ORS.

Unlike many diseases, for which no cure exists, the cure for diarrhea has been around for decades and is cheap and available. We just have to find the financial, technical and social means to get it to people who need it, and help them use it to protect the health of their families.

This infographic shows the status of the war against pneumonia and diarrhea in the world’s poorest children.

 

How Does Global Health Fare in the Sustainability Development Goals?

28th Sep 2015

By David J. Olson

Last weekend in New York City, world leaders formally approved the Sustainability Development Goals (SDGs), which will guide development efforts over the next 15 years. They replace the Millennium Development Goals (MDGs) that were signed in 2000 and expire on Dec. 31, 2015.

The MDGs were terrific for global health, both in raising money, and raising its profile on the global agenda.

Health related Millennium Development Goals

Health related MDGs

Eight goals made up the MDGs, and three of them were entirely focused on health. In addition, two other goals included health-related targets. Eight (38%) of the 21 total MDG targets were health-related, and seven of those targets were numerical (i.e. reduce maternal mortality by three quarters).

Between 2000 and 2014, $228 billion was allocated to address the three health-related MDGs, according to the Institute for Health Metrics and Evaluation (IHME)  (see my July blog here on Global Health TV for more information).

More importantly than how much was raised, serious progress was made on many of these health fronts. For example, two weeks ago, the World Health Organization announced that malaria death rates have plunged by 60% since 2000 and that the malaria target to have halted and begun to reverse the incidence of malaria by 2015 has been met “convincingly.” Most people think the Target 1A to halve the proportion of people living on less than $1.25 has been met.

But where is health in the SDGs? The answer to that question contains both good and bad news for global health advocates.

The bad news is that health is much less prominent in the SDGs. The SDGs comprise 17 goals, only one of which is health-related:

Goal 3: Ensure healthy lives and promote well-being for all at all ages

Sustainability Development Goal 3

SDG 3- Good Health and Well-being

Those 17 goals have 169 targets and Dr. Christopher Murray, director of the IHME, has identified 23 of them (13.6%) as being health-related. You can view those 23 health-related targets in his article in the New England Journal of Medicine (see graphic on the right within the article).

“If we consider health in the SDGs in light of the factors that contributed to progress toward the health-related MDGs, there are reasons for concern,” Dr. Murray writes. “Health clearly does not occupy the central role in the SDGs that it did in the MDGs. There is only one specifically health-focused goal though a number of other factors that affect health (such as water, sanitation, poverty, and gender equality) are targets in other goals, leading to a total of 23 health-related targets. Inevitably, health’s lower profile in the goals will mean less national-level political attention beyond the health sector. Within the health sector, the more diffuse agenda may mean less progress in addressing the challenges that the MDGs prioritized.”

Even more worrisome is the fact that Dr. Murray says that only 13 of the 23 health-related targets are framed quantitatively and that “targets without concrete quantification probably won’t receive consistent attention

GH_Sept2015_Globalgoalsjpg

Another concern is the extent to which the SDGs address or do not address sexual and reproductive health. There are two targets that explicitly mention sexual and reproductive health Target 3.7 and 5.6.

“The SDGs are comprehensive, visionary and inspiring in many ways. But they fall short: they take a narrow view of sexual and reproductive health and rights, one of the most crucial, but also most controversial, parts of the SDG agenda,” writes Ann Starrs, president and CEO of the Guttmacher Institute, in The Lancet.

“The SDGs are not likely to encompass other important elements of sexual and reproductive health and rights, including safe abortion, non-discrimination based on sexual orientation or gender identity, and the importance of high-quality, confidential and timely sexual and reproductive health services.”

The good news is that the SDGs cover some critical areas of global health that were totally ignored by the MDGs. I am thinking specifically of health issues that account for much of the global burden of disease, like non-communicable diseases (such as cancer, cardiovascular disease, diabetes, mental disease and respiratory disease), substance abuse and traffic accidents. Target 3.4 of the SDGs states that:

By 2030, reduce by one-third premature mortality from non-communicable diseases through prevention and treatment, and promote mental health.

“This victory marks the culmination of a six-year campaign led by the NCD Alliance”, said José Luis Castro, chair of the NCD Alliance and executive director of the Union Against Tuberculosis and Lung Disease last Friday. “In 2009 when the NCD Alliance was founded, one of the four initial goals was to secure NCDs namely diabetes, cancer, cardiovascular diseases, chronic respiratory disease, and mental/neurological disorders in the successors to the MDGs. Since then, the NCD Alliance has worked tirelessly with many partners and stakeholders to lay the foundations for this historic agreement today.”

This infographic shows how the SDGs will address the NCDs.

The process of developing the SDGs was tortuous and time-consuming but two even greater challenges lay ahead.

First, how do we measure whether the targets are being met, so citizens can hold their governments accountable? The UN has set a deadline of March 2016 for development of the accountability framework.

Second, who will pay for the SDGs? Estimates vary but “analysts say it could cost as much as $4.5 trillion per year in state spending, investment and aid,” according to a backgrounder from the Council on Foreign Relations. That’s a huge question but one that was starting to be addressed last weekend, when UN Secretary-General Ban Ki-moon announced over $25 billion in initial commitments over five years to help end preventable deaths of women, children and adolescents.

It’s Too Soon to Declare Victory over Ebola Virus

24th Aug 2015

By David J. Olson

There has been a welcome spate of good news coming out of West Africa in recent weeks on the apparent demise of Ebola, which has caused the region nothing but misery, illness (27,952 reported cases) and death (11,284 reported deaths) for over a year.

  •  Ebola cases continue to fall. For the week ending Aug. 16, no new cases were reported in Liberia and Sierra Leone, for the first time, has gone one full week without any new cases. Guinea was the only country to report any new cases but just three.
  •  The Lancet published “interim results” from research on the efficacy of an Ebola vaccine in Guinea showing a vaccine efficacy of 100%.

 

The news is undeniably good. In the last week, I read these headlines:

Associated Press: “ UN official: Ebola epidemic could be defeated by end of 2015.”

Scientific American: “Does This Ebola Vaccine Herald the End of the Virus?”

National Public Radio: “Zero Ebola Cases Reported in Sierra Leone as Epidemic Peters Out”

 

This is all welcome news but if you go beyond the headlines you quickly realize that this epidemic is not yet over.

World Health Organization's weekly Ebola situation reports

World Health Organization’s weekly Ebola situation reports show the great difference between the state of the Ebola epidemic on Aug. 19, 2015 (above) and Nov. 26, 2014 (below).

World Health Organization's weekly Ebola situation reports

 

The World Health Organization, in its most recent Ebola situation report of Aug. 19, cautions against premature declarations

of victory in the very first paragraph:

“However, there is still a significant risk of further transmission. In addition to the large number of contacts who remain under observation in Guinea and Sierra Leone, 45 contacts have been lost to follow-up in the Guinean capital Conakry over the past 6 weeks. Several high-risk contacts have also been lost to follow-up in the Sierra Leonean capital, Freetown. Rapid-response teams remain alert and ready to respond to further cases.”

Until all of these contacts pass the 21-day follow-up period, there is every reason to suspect more Ebola cases. And the vanished contacts in Conakry and Freetown are cause for concern.

 

Virologist Ian Mackay of the Australian Infectious Diseases Research Centre writes in this blog that this good news is subject to caveats.

“Those blissful stretches [of zero cases] may be punctuated by a case arising from parts unknown. They may be tracked to a sexual transmission event, or their origins may never be fully understood … So we’re not at all free and clear of this virus yet. It’s still a long haul with many weeks of anxious waiting and heightened vigilance as well as the need to retain the capacity to cope with new cases. But, that said, we do seem to have taken one more step back from the precipice we once started into as we imagined an Africa fending off a rolling Ebola epidemic.”

And as for the exciting news of the Ebola vaccine with 100% efficacy, this article on WIRED explains why that number means less than you think. One of the problems is that the findings are based on incomplete data, according to WIRED. Another challenge is that since the vaccine was tested while the epidemic was receding, it is difficult to know if the vaccinated people who didn’t develop Ebola in the trial were protected by the vaccine or simply benefited from the decline of the epidemic.

Clearly, this is a breakthrough (for there is nothing else available against Ebola) and very encouraging. But, just as clearly, more data is needed to know how efficacious this vaccine really is. And then there’s the significant challenge of getting the vaccine to those who need it once we know that it works.

The other major challenge is to restore, and then strengthen, the health systems of Guinea, Liberia and Sierra Leone, which were weak even before the epidemic. It will be hard to do that without well-trained and well-motivated health workers. Their ranks were decimated by Ebola: A little-reported fact of the epidemic is that the three countries reported 880 confirmed health worker infections since the start of the outbreak, with 512 deaths, according to the WHO.

Craig Spencer, a doctor from New York who was one of four people stricken with Ebola in the U.S., addressed this challenge in The New York Times last week:

“If the epidemic’s immediate impact on the West African health system sounds dire, the probable consequences are even more unsettling. Immunization levels have dropped across all three countries, so that, for instance, a regional measles outbreak could cause hundreds of thousands of cases and potentially more deaths than Ebola. A recent World Bank report estimated that maternal mortality could skyrocket, setting the entire region back with rates not seen in almost two decades.”

Just restoring the health systems to what they were before Ebola will be a huge challenge. Improving them beyond that status quo, so they are better able to deal successfully with epidemics of the future will be even more daunting. But it must be done. The governments of the three countries must lead the way, with significant help from the international community.

 

 

Global Health Funding: Huge Increase Since 2000 But Also Huge Disparities

27th Jul 2015

By David J. Olson

As the end of the era of the Millennium Development Goals (MDGs) (2000-2015) draws near, we who work in global health can look back with some satisfaction at the $228 billion that was allocated to address the three health-related MDGs during that time.

 

Although spending grew rapidly in the first ten years, it was stagnant between 2010 and 2014, and actually decreased by 1.6% between 2013 and 2014. Global health funding in 2014 amounted to $36 billion in 2014 (of which $1 billion was for Ebola).

 

That information comes from Financing Global Health 2014: Shifts in Funding as the MDG Era Closes, the annual report of global health funding published last month by the Institute for Health Metrics and Evaluation (IHME).

 

And two weeks ago, the Kaiser Family Foundation and UNAIDS issued a report that showed that although there was only a slight increase in funding for HIV in low- and middle-income countries in 2014 (less than 2%), seven of 14 donor countries actually decreased funding despite the recent gains made against the epidemic.

 

The United States continued to be the largest source of funds, both for general development assistance for health (DAH) and for HIV/AIDS. It provided $12.4 billion in DAH and $5.6 billion in HIV funding in 2014, though the HIV funding remained “essentially flat,” according to Kaiser/UNAIDS. The U.K. was Number 2, with $3.8 billion in DAH and $1.1 billion in HIV funding in 2014.

 

The amount of money provided by the big Western donors to save lives and fight disability over the last 15 years has been undeniably tremendous but what is equally impressive and less noticed is that spending by low- and middle-income countries themselves reached an all-time high of $711 billion in 2012, growing almost 10% from 2011 to 2012. The report says that this contrast (between donor and local health spending) “hints at new trends in global health financing.”

 

“While a great deal of attention is focused on donors’ efforts to improve health in developing countries, the countries themselves invest much more money,” said Dr. Joseph Dieleman, assistant professor at IHME and the report’s main author. “For every one dollar donors spend in global health, developing countries spend nearly $20. However, in some low-income countries, it’s one donor dollar for every dollar spent by the country.”

 

What has always puzzled me are the huge disparities between global health spending and the global disease burden, which reveals where disease, death and disability are actually occurring.

 

For example, IHME reported the leading causes of deaths in the world in 2013 as ischemic heart disease, stroke, chronic obstructive pulmonary disease, pneumonia, alzheimer’s disease, lung cancer, road injuries, HIV/AIDS, diabetes and tuberculosis, in that order.

 

Lancet reported the leading causes of deaths of children 1-59 months in 2013 as lower respiratory infection (19%), non-communicable diseases (16%), malaria (16%), diarrheal disease (13%), road injuries (8.7%) and nutritional deficiencies (7%). HIV/AIDS was 1.7%.

 

But the biggest recipients of DAH in 2014, according to IHME’s new report, are HIV/AIDS (30.3%), newborn and child health (18.5%), maternal health (8.4%), health sector support (6.6%), tuberculosis (3.8%) and non-communicable disease (1.7%). The rest is “other” or “unallocable.”

 

In maternal and child health, donors spent $3.2 billion on child vaccines, $1.1 billion on child nutrition and $778 million on family planning in 2014, IHME reports. In recent years, DAH for vaccines and nutrition experienced major gains, but funding for family planning remained “relatively stagnant.” Family planning will never show up in the global disease burden (because it is not a disease) but it could reduce all of the causes of death listed above because it will allow women to avoid unwanted pregnancies.

 

In comparison, says IHME, DAH for addressing mental health and combatting tobacco use was much smaller, amounting to $164 and $31 million respectively, in 2014. (See my Global Health TV blog last month for more on the great disparity between the need and funding for mental health in Africa).

 

Clearly, the money is not always going where the disease, death and disability is occurring. I asked IHME which health areas have the greatest disparities. They told me:

 

“Among the different disease-specific funding areas we track, the disparities between disease burden and funding are most extreme in HIV/AIDS on the high end and in non-communicable diseases on the low end. Some countries receive more than $500 per DALY (disability-adjusted life year) for HIV/AIDS (Libya, Morocco, Namibia, and Tunisia), while the countries receiving the highest amount of funding for non-communicable diseases receive around $20 per DALY (Tonga and The Gambia).”

 

A review of cost-effectiveness studies of DAH going to low- and middle-income countries in the July issue of Health Affairs found the relationship between health aid and incremental cost-effectiveness ratios “is negative and significant” and that “changing the allocation of health aid earmarked funding could lead to greater health gains even without expanding overall disbursements.”

 

I’m certainly not arguing for reducing the amount of money going to fight HIV/AIDS not when we have a realistic change of eliminating it by 2030 or other health areas that have benefitted greatly from global health funding trends over the last 15 years. But I am arguing for better funding of areas that occupy a huge part of the global disease burden, like non-communicable disease, and are getting too few resources.

 

Here’s where you can find the full report Financing Global Health 2014: Shifts in Funding as the MDG Era Closes. And here’s a one-page summary. This graph by National Public Radio shows the amount contributed by the U.S. as a percentage of total funding for major global health areas in 2014.

Huge Gap Between Need and Funding of Mental Health in Africa

29th Jun 2015

By David J. Olson

Sean Mayberry has spent his entire life surrounded by mental illness. As a child and an adult, people close to him have endured this affliction. But he had an epiphany when he happened upon a young man behind a farmhouse in Uganda, sitting in his own excrement and digging in the dirt.

“It was a turning point for me,” he recalls. “I left that young man knowing that I had to do something for the mental health of that continent.  He gave me the courage to try to make a difference for some of his mentally ill brothers and sisters.”

Pauline Muchina is dealing with mental illness in her family in Kenya. Her 50-something sister lost her job due to depression and had to come home to live with her mother. She is now on medication and attends counseling.

Muchina also has a nephew suffering from depression. While in a government hospital, he was chained to a bed for one week and his condition got worse. Now the family has found a private rehabilitation center for him. He is getting better but it is costing the family $2,500 for six months. Muchina’s family is middle-class and can pay the treatment (with difficulty), but the vast majority of Kenyans could never afford such expensive treatment.

Mental disorders and substance abuse are the third greatest contributor to the global burden of disability with 23% of the burden – greater than cardiovascular disease or cancer.

Yet the amount of resources expended on them is miniscule: A paper published earlier this month shows that the amount of development assistance for health attributed to mental health is less than 1%. And low-income countries themselves spend only 0.5% of their very limited health budgets on it, according to FundaMentalSDG, an initiative to strengthen mental health in the post-2015 agenda.

Adolescent boys in talk therapy group near Kampala, Uganda.  Credit: StrongMinds

Adolescent boys in talk therapy group near Kampala, Uganda. Credit: StrongMinds

Here are some other facts about mental health, according to the World Health Organization (WHO):

 

Depression alone accounts for 4.3% of the burden of disease – with more than 350 million people all ages suffering from it – and is among the largest single causes of disability worldwide, particularly for women.

- To describe the current accessibility of mental health services in Africa as deficient would be a gross understatement. Almost half of the world’s population lives in countries where there is only one psychiatrist to 200,000 or more people, according to the WHO. Ninety percent of African countries have less than one psychiatrist per 100,000 people.

- Around 20% of the world’s children and adolescents have mental health problems.

- About 800,000 people commit suicide every year.

- Wars and disasters have a huge impact on mental health

- Mental disorders increase the risk of getting ill from other diseases such as HIV, cardiovascular disease and diabetes, and vice versa.

- In Africa, human rights violations of people with mental and psychosocial disability are common.

 

A 2011 study by Harvard School of Public Health estimated that the cumulative global impact of mental disorders in terms of lost economic output amounted to $2.5 billion in 2010, estimated to increase to $6 billion by 2030. The share of this in low- and middle-income countries is $870 million and $2.1 billion, respectively.

In fact, Mayberry makes the case that depression also reduces the effectiveness of development programs.

“When you have 25% of the population that is depressed in many African countries, these individuals do not respond to the variety other development efforts which aim to get them to practice safe sex or follow tuberculosis treatment protocols, for example,” says Mayberry. “Depression inhibits their ability to focus and concentrate, so donors end up wasting a vast amount of their development dollars trying to change the behaviors of these depression sufferers.”

Muchina says that mental health affects all areas of life including family and human relationships. “Someone with depression and low self-esteem is not going to do much to better her or his life,” she says. “A lot of violence against women and girls can be traced back to mental instability of the abusers. Most women who stay in abusive relationships, or fail to report abuse, also have mental and emotional issues. I believe that this has enabled abuse to go on from generation to generation. “

Mayberry created StrongMinds, to provide Africans with access to mental health.  In Uganda, StrongMinds is showing that using ordinary people from African communities to deliver mental health care through talk therapy – in many cases without medication – can be surprisingly effective. This is huge, because mental health professionals are scarce and medication expensive.

StrongMinds has treated over 1,000 women with depression in the last year using 12 weeks of group talk therapy led entirely by trained employees who are not mental health professionals. The New York Times described this as “a depression-fighting strategy that could go viral.”

Muchina says some Kenyan pastors, like her sister Anne, are counseling depression sufferers without psychotherapy training. In most cases, these pastors are the only hope for people encountering mental health challenges.  If these pastors could be trained, she says, thousands of counselors could be put to work.

For over 15 years, Muchina has been supporting orphans and vulnerable children affected by HIV/AIDS, which gives these children a second chance in life, through the Future African Leaders Project. Muchina says that all of the young people participating in the Future African Leaders Project have suffered some form of trauma that require psychotherapy or counseling. Government help is virtually non-existent and the project cannot afford private care for all of the youth.

“In 2013, we lost a 21-year-old man to suicide,” Muchina says. “He was suffering from depression and got into alcoholism – a nightmare combination. His brother is going through the same thing, and I worry about losing him, too.”

The world’s plan for dealing with mental health in Africa, and other developing countries, is embodied in WHO’s Mental Health Gap Action Programme (mhGAP), developed in 2008.  In 2013, the World Health Assembly adopted the WHO’s Mental Health Action Plan 2013-2020, which is global and designed to provide guidance for national action plans in all resource settings. Africa even developed its own Declaration of Mental Health in Africa last year.

Mental health was absent from the Millennium Development Goals, expiring this year, and some advocates fear that they will be similarly neglected in the Sustainability Development Goals (SDGs)now being finalized.

“I greatly fear that, despite a real and determined push to place mental illness more squarely on the SDGs, we will once again fail mentally ill people everywhere,” says Chris Underhill, founder president of BasicNeeds. “My fear is that the new SDGs will pass into international convention and once again the global community will have badly let mentally ill people down. Surely global development organizations and governments have to commit to the principle of proper access to treatment for the 450 million people who suffer mental ill health globally at any one time.”

For wrenching images of mental health disorders in Africa, view this visual report from PBS NewsHour, “Mentally ill shackled and neglected in Africa’s crisis regions.”

Women Trying to Regain Dignity by Ending Fistula

27th May 2015

By David J. Olson

BAMAKO, Mali Djantou came here from Fangala, her village northwest of Bamako, to repair her fistula, a hole between the birth canal and the bladder or rectum caused by prolonged, obstructed labor without adequate treatment. Djantou’s fistula occurred while she was in labor during her first pregnancy. Her child was stillborn. She wants to have children in the future but she is afraid both of the operation and of childbirth. Djantou is 15 years old.

Rokia is from the village of Tarasso, near the border with Burkina Faso. Twenty years ago, she also developed fistula during her first pregnancy. The baby was stillborn. “The urine would not stop,” she said. Rokia has had two operations but both failed. She is now awaiting her third operation. Although she is 40 years old, she still very much wants to have children.

 

Djantou

Djantou

Rokia

Rokia

Fistula is a tragic condition that leaves women leaking urine, feces or both. It can lead to chronic medical problems and cause social exclusion. Women are often abandoned by their husbands and sometimes by their own families because of their incontinence and unpleasant smell. They face depression and social isolation either self-imposed or by their sometimes unforgiving communities.

Last Saturday, May 23, marked the International Day to End Fistula. The theme for this year is “End Fistula. Restore Women’s Dignity.” The Campaign to End Fistula, launched by the UN Population Fund (UNFPA) and partners in 2003 is now present in 50 countries across Africa, Asia and the Arab region.

Fistula is considered a disease of poverty because it occurs mostly in very poor countries with inadequate health care.  An estimated 2 million women in sub-Saharan Africa, the Middle East, Asia and Latin America and the Caribbean are living with the affliction, and some 50,000 to 100,000 new cases occur each year, according to the UNFPA.

I met Djantou and Rokia this month at Point G Hospital, on the rocky hills overlooking Bamako, along with two other women suffering from fistula. They are at Point G as part of Capacity Building for Fistula Treatment and Prevention, a five-year project implemented by IntraHealth International and funded by the U.S. Agency for International Development. The project builds on the success of a previous USAID-funded fistula project that ended in 2013. That project:

 

  • Provided operations for 460 women with a success rate of around 75%.
  • Trained 18 surgeons in fistula surgery.
  • Trained 890 health providers in counseling, infection prevention, nursing care and integration of family planning in fistula surgery.

“Fistula is almost entirely preventable for women who have access to skilled health workers for prenatal care and assisted delivery, and who are supported by health systems that provide reliable emergency obstetric care, including cesarean sections,” wrote Cheick Touré, Mali country director for IntraHealth.

Family planning is critical to the success of the fistula repair, said Touré.  It is vital that the women avoid pregnancy for 6-12 months after surgery to ensure the success of the operation.

Three of the four women I interviewed had been abandoned at least once by a husband. The case of Djantou is more complicated: She says she is still married but her husband has left and she has no idea when he is coming back. Happily, all four women have received support from their own families.

But even though Rokia’s family has supported her, she doesn’t go out in the village because her fistula is too embarrassing when she stains her clothing or furniture. She says there’s a man who wants to marry her but only when she is cured of fistula. Her marital and social status hangs on the fate of the operation she is awaiting.

Here’s a poignant video about a fistula project in the Democratic Republic of Congo implemented by Management Sciences for Health and a slide show on the Fistula Care Plus Project in Bangladesh implemented by EngenderHealth. To learn more about how you can help restore dignity for women living with fistula, visit IntraHealth’s Restore Dignity Campaign.

 

How Mali Conquered Ebola

28th Apr 2015

By David J. Olson

BAMAKO, Mali In the year-old Ebola epidemic, most of the attention has justifiably been focused on Guinea, Liberia and Sierra Leone, where the vast majority of the cases (26,044) and deaths (10,808) have taken place. But what about those countries that have successfully controlled Ebola Mali, Nigeria, Senegal, Spain, the UK and the US which account for only 35 cases and 15 deaths?

I am spending two months in one of those countries and wondered how Mali conquered Ebola . Even though the World Health Organization (WHO) had declared Mali Ebola-free in January, I had barely stepped off my airplane at Bamako–Sénou International Airport on March 14 when I encountered Ebola control: I was scanned for a fever and offered hand sanitizer before entering the airport terminal.

These signs -- which say "Stop the Ebola virus: Wash your hands regularly with soap" are still ubiquitous around Bamako three months after WHO declared Mali Ebola-free.

These signs — which say “Stop the Ebola virus: Wash your hands regularly with soap” are still ubiquitous around Bamako three months after WHO declared Mali Ebola-free.

Mali went on high alert after confirming its first case of Ebola in late October of last year, when a 2-year-old girl who had traveled from Guinea to Mali died. The country moved quickly in what the government considered an emergency situation. The child, who was symptomatic upon her arrival in Mali, had traveled extensively in the country using public transportation. Aggressive contact tracing was undertaken but none of the contacts showed symptoms.

It looked like the country had dodged a bullet, with only one death. But then an imam from Guinea was admitted to Bamako’s prestigious Pasteur Clinic with a diagnosis of acute kidney failure, and died on Oct. 27. That case set off a chain of transmission that led to seven additional Ebola cases and five deaths, including a doctor and nurse who had treated the imam. He was buried with full traditional rites, including washing of his highly contagious body, which may have exposed mourners to the virus.

The government put the clinic and the imam’s mosque in full lock down. By Nov. 18, 600 people were being monitored and 90 people were quarantined, including about 20 U.N. peacekeepers who had been treated at the clinic for injuries sustained on duty.

The Ministry of Health launched campaigns with information about how to avoid Ebola in French and several local languages, mostly focused on hand-washing, and established a telephone hotline which eventually received 6,000 calls per day. Calls were analyzed to determine where public messages needed to be tweaked. Some callers reported suspected cases. All such reports were investigated but no further cases were found.

As a result of the information campaigns, some traditional practices were altered. Malians told me they avoided shaking hands and instead greeted people with a wave or by clasping their own hands and bowing. Sometimes they avoided eating from the same dish, which is the norm in Mali and many other countries in Africa, and changed their burial rituals. Some reportedly kept their children from playing with other children.

People started washing their hands more and hand sanitizer became widely available, something that was not previously common in Mali. At some churches, bottles of hand sanitizer appeared at the door and the passing of the peace was discontinued. Even now, in April 2015, billboards promoting hand-washing are ubiquitous around Bamako.

PSI Mali Country Representative Alex Brown believes that hand-washing was overemphasized during the Ebola crisis in Mali. Brown has two main problems with the emphasis on hand-washing.

“First, it doesn’t address the known transmission vectors that account for the vast majority of Ebola cases – like touching dead bodies at funerals, inadequate clothing and protection for care-givers of sick people, transportation of sick and dead people and eating wild animals,” said Brown. “Second, now that the country is Ebola-free, if you were washing your hands to prevent Ebola, you can now stop or neglect hand-washing, right? That’s a bad outcome, because hand-washing is a great thing for a thousand other reasons.”

Several Malians told me that many of the good practices adopted during the crisis have been abandoned now that Ebola is in the past. For example, hand sanitizer has become much less common.

But whatever Mali did, it was enough to eradicate Ebola. On Jan. 18, WHO declared Mali Ebola-free after 42 days with no new cases.  There were several reasons for that: Mali had its own high quality laboratories, which facilitated rapid detection of cases. Contract tracing was rigorous and most contacts were monitored in isolation. The information campaigns communicated prevention measures to people throughout the country in a variety of languages. And Mali learned from Guinea, Liberia and Sierra Leone.

“I think what was different in Mali is that we learned from the other countries and were prepared,” said Bijou Muhura, the Ebola coordinator for the U.S. Agency for International Development in Mali. “There was a team of WHO and CDC (Center for Disease Control) experts in the country when we had the first case. They were here to help with preparedness and that got shifted to actions. The U.S. government team worked very closely with all agencies, and with all other donors and partners including WHO, Médecins Sans Frontières and the UN Mission for Ebola Emergency Response.”

West Africa Finally Starting To Embrace Family Planning

24th Mar 2015

By David J. Olson

BAMAKO, Mali When my wife and I lived here in the late 1980s and early 1990s, our housekeeper, Korotumu, hid her birth control pills on the top shelf in our kitchen, so her husband would not find out she was using contraception. He was unemployed and they had two children. Koro figured that two was enough, at least as long as her husband was not working.

I didn’t realize it then, but Koro was in a progressive minority of Malian women at that time. The 1987 Demographic and Health Survey of Mali revealed only 1.3% of married women were using modern contraception and the fertility rate (the average number of children a woman has in her lifetime) was 7.1. Koro was part of that 1.3%.

A service provider attends to Modinat Bamidele, a family planning client at the family planning unit in Orolodo primary health centre in Omuaran township in Nigeria’s central state of Kwara. © 2012 Akintunde Akinleye/NURHI, Courtesy of Photoshare

Service provider attends to a family planning client at the family planning unit in Orolodo primary health centre in Omuaran township in Nigeria’s central state of Kwara.
© 2012 Akintunde Akinleye/NURHI, Courtesy of Photoshare

Flash forward a quarter of a century and what has happened in Mali? Use of modern contraception has increased to 9.9% and the fertility rate has dropped from 7.1 to 6.1.

This paltry progress is far less than we have seen in other parts of the world, even in Eastern and Southern Africa, in countries like Ethiopia, Kenya and Malawi. More importantly, it is far from what Malian women themselves want: The unmet need for family planning for women “in union” is 26%, and for women not in union who are sexually active, it is a whopping 55%, according to the 2012-2013 DHS.

Taken together, the nine French-speaking countries of West Africa have the lowest modern contraceptive use and the highest fertility rate in the world. The modern contraceptive prevalence rate (CPR) for all of sub-Saharan Africa is 23%; in West Africa, it’s 11%. The highest modern CPRs in West Africa (not including the island nation of Cape Verde) are Senegal with 20%, Liberia with 19% and Ghana with 18%. More typical are Mali and Nigeria, the seventh most populous country in the world, both with only 10%.

But West Africa is on the verge of change. One manifestation of that change is the Ouagadougou Partnership, an initiative of nine French-speaking, West African countries to promote family planning that started in 2011. At its annual meeting in December, the Partnership announced that new data from 2013 shows the nine countries are on track to reach their goal of creating one million new users with modern contraception by 2015.

“You might say that 1 million is not a lot for nine countries together but to reach that 1 million each country has to double its CPR in three or four years, which is tremendous,” says Fatimata Sy, director of the Coordination Unit of the Ouagadougou Partnership. “It’s really a challenge and very ambitious.”

“Family planning is going to happen in West Africa,” says Roy Jacobstein senior medical advisor of IntraHealth International. “In organized programs, we’re trying to make it happen faster. But you can already see it happening naturally in the cities and the higher wealth quintiles. It’s only a question of how soon it happens.”

Senegal is already an emerging family planning success. It experienced a significant increase in modern contraceptive prevalence from only 12% in 2011, to 16% in 2013, and 20% in 2014. Sy said that the previous average CPR growth rate was 0.5% to 1% per year, and points out three other countries that that she considers emerging family planning successes Burkina Faso, Niger and Togo.

Even in Mali, you can see the signs of change in the cities and the higher wealth quintiles. Modern CPR is 22.5% in Bamako and 23.3% in the highest wealth quintile. Jacobstein says those contraceptive users are the leading indicators of a wave that is coming.

There are many reasons why West Africa has been behind the rest of Africa. One of the big reasons is the weakness of the health systems. Even in countries with large unmet need (like Mali), many women cannot access contraception or, if they can, many cannot afford it.

Sy says the social norm is early marriage and having lots of children. “The more children you have, the better you feel,” she says.

There’s been little money for family planning, especially in Francophone countries.

Religion plays a strong role in West Africa and many people feel, rightly or wrongly, that their religion is against family planning.

But all of these things are now changing. Jacobstein says urbanization has forced people to evaluate their lifestyles. “What is it about urbanization?” he says. “Living quarters are smaller, it’s harder to feed people and pay school fees. The calculus among families is that it is smarter to invest more per child in fewer children. We’ve also had success in child survival so people no longer feel they need to have eight children so that five will survive.”

Even some religious leaders are starting to champion family planning.

“The most fundamental change in family planning in the last 50 years is going from ‘You have the number of children that God wants’ to ‘You have the number of children that you and your spouse want,’” says Jacobstein. “People can see the link between smaller, healthier families and a better economic situation. That’s what happened in Southeast Asia. That’s what happened in Latin America. And now it’s starting to happen in West Africa.”

When Koro was using oral contraceptives and hiding them from her husband in the 1980s and 1990s, she was clearly an outlier. Increasingly, she would be considered the mainstream.

 

Stymied by Less Smoking In Richer Countries, Big Tobacco Shifts Focus to Developing Countries

2nd Mar 2015

By David J. Olson

Between 1990 and 2009, cigarette consumption decreased by 26% in Western Europe, but in Africa and the Middle East, it increased 57%, according to the American Cancer Society (ACS). In response, many of these developing countries are stepping up their efforts to fight tobacco with new laws and restrictions. Big Tobacco is using its deep pockets to finance creative attempts to circumvent those laws.

 

Anti-tobacco demonstrators demand implementation of the national Tobacco Control Law passed in 2011.  Credit: Aliança de Controle do Tabagismo

In Brazil ,anti-tobacco demonstrators demand implementation of the national Tobacco Control Law 
Credit: Aliança de Controle do Tabagismo

 

The problem is so daunting that ACS named rising use of tobacco in developing countries as one of it “Three Top Cancer Challenges of the 21st Century” earlier this month when it observed World Cancer Day. Comedian John Oliver covered the issue very well in this segment from his HBO show “Last Week Tonight.”

 

An estimated 8 million of the 14.1 million new cancer cases diagnosed in 2012 occurred in developing countries with 82% of the world’s population, according to Global Cancer Facts & Figures, 3rd Edition. Smoking causes at least 12 types of cancer, according to the U.S. Surgeon General, and accounts for a fifth of all global cancer deaths. Tobacco use is the cause of nearly 6 million premature deaths annually, notes the report.

 

Not all cancers can be prevented, but all cancers caused by tobacco can. That is why the fight against tobacco consumption is so important.

 

Anti-tobacco demonstrators demand implementation of the national Tobacco Control Law passed in 2011.  Credit: Aliança de Controle do Tabagismo

In Brazil, anti-tobacco demonstrators demand implementation of the national Tobacco Control Law passed in 2011.
Credit: Aliança de Controle do Tabagismo

The Framework Convention on Tobacco Control (FCTC) is the main global treaty on tobacco control, and 180 countries (out of 196) have ratified it (but not the U.S.). About 90% of the world’s population falls under the FCTC’s protections. Some of the main provisions of the FCTC are regulation of the contents, packaging and labeling of tobacco products, and comprehensive bans on tobacco advertising, promotion and sponsorship. The 27th of February is the tenth anniversary of the FCTC.

 

Some of the tactics for fighting tobacco now being implemented, or considered, by developing countries include:

 

  • Marketing Bans: Despite the fact that many countries have imposed restrictions on tobacco advertising, the tobacco industry still spends almost $10 billion on marketing (2008). Complete bans on tobacco advertising, promotion and sponsorship decrease tobacco use, reports the World Health Organization, but only 24 countries have complete bans on such activities. “The traditional marketing of tobacco products is being more and more regulated,” says Michal Stoklosa, an economist at the American Cancer Society. “That is why tobacco companies are moving toward point-of-sale advertising as well as sponsorship and corporate social responsibility.” But only 67 countries have banned point-of-sale advertising, says Stoklosa. In 2013, the government of Kenya pledged to enforce legislation to ban advertising and promotion of tobacco products, and Stoklosa says Kenya has done an exceptional job of implementing the ban.
  • Warning labels: Health warnings on cigarette packaging are now required in most countries but the degree of the warnings vary by country. The FCTC requires that they cover at least 30%, and preferably 50%, of the visible area of the pack. Some countries require pictorial warnings but most do not. Sri Lanka’s Ministry of Health has just ordered tobacco manufacturers to place graphic warnings about the dangers of smoking on cigarette packs, and it must cover at least 60% of the visible area. And in April 2015, India will go further and require pictorial warnings to cover 85% of the package.
  • Plain cigarette packaging: Cigarette manufacturers have a knack for making their products look appealing. In response, some countries are considering laws that require plain cigarette packaging with limited colors and standardized fonts. A Cancer Research UK campaign for plain cigarette packaging made this video, which brilliantly captures what tobacco foes are up against. So far, only Australia has implemented these plain packs.

 

I have previously written about tobacco control efforts in Brazil, which were supported by ACS’s “Meet the Targets” program. In 2011, Brazilian President Dilma Roussef signed tough anti-tobacco measures into law. The law called for advertising restrictions, stronger warning labels, higher taxes and smoke-free places. However, it took another year and a half of intense efforts by a civil society coalition led by Aliança de Controle de Tabagismo (ACT) before government issued a decree in May 2014.

 

Anti-tobacco demonstrators demand implementation of the national Tobacco Control Law passed in 2011.  Credit: Aliança de Controle do Tabagismo

In Brazil, anti-tobacco demonstrators demand implementation of the national Tobacco Control Law 
Credit: Aliança de Controle do Tabagismo

ACT told me that the law, which went into effect Dec. 3, 2014, got a huge amount of media coverage as part of an effort to educate people on the law and what it does. Last month, coalition members organized street events with volunteers wearing the campaign’s T-shirt and distributing information about the law, while artists painted the campaign logo on walls. An advertising campaign was launched in social media in December and on radio, newspapers, billboards, buses and elevators in 11 of the 26 states of Brazil.

 

Last year, when Philip Morris, the manufacturer of Marlboro, was running a major Marlboro campaign called “Be Malboro” in Brazil, ACT and the Campaign for Tobacco-Free Kids criticized the campaign for being a new “youth seduction for smoking,” demanding that it be discontinued in Brazil and asked the Roussef administration to fully implement and enforce the 2011 law. Philip Morris responded that the campaign was aimed “exclusively” for adult smokers.

 

These efforts are welcome but much more work needs to be done in order to make a dent in the 8 million deaths from tobacco that are expected by 2030.

 

The American Cancer Society will release the 5th edition of the Tobacco Atlas on March 18, when you will find it at this website.

 

Family Planning in India and Pakistan: Trying to Pick Up the Pace of Change

27th Jan 2015

By David J. Olson

Last month, I met Sumeera, 26, in a Dhanak clinic (“dhanak” means rainbow in Urdu) in the village of Wallah, in the rural Punjab of Pakistan. She and her husband have four children ages 7, 5, 3 and 1, and have agreed that four is enough. She had come for a pregnancy test and to secure a contraceptive method to keep her family from getting bigger. Her pregnancy test was negative, and she went away happily, with an intrauterine device inserted by her Dhanak midwife and clinic owner Kaneez Fatima. “Before we found Dhanak, my husband and I knew about family planning but did not have access to it,” Sumeera told me. “Dhanak made a big change in my life.”

One thousand four hundred kilometers to the southeast and a week later, I met Birula, 25, in a Surya clinic (“surya” is the Hindi word for sun) in Ara, a rural town about two hours outside of Patna, India, the capital of Bihar state. She has three children ages 7, 6 and 1½. The previous week she had been sterilized at this clinic; she was back to have her stitches removed. Her relief was palpable – she couldn’t stop smiling.

Sumeera and Birula come from different cultures in different countries but the problems they face are remarkably similar – too many children and too little ability to control the size of their. In India, women cannot always determine the size of their families because of a strong preference for the male child and male dominance in decision-making. In Pakistan, religion also plays an influential role. Both countries are confronting the problem, albeit in different ways and with varying degrees of success.

India, the second largest country in the world, has a population of 1.3 billion, and Pakistan has 194 million, making it number six. If current trends continue, India will overtake China to become the world’s largest country, and Pakistan the fifth biggest, by 2050, according to the Population Reference Bureau. But governments of both countries are determined that current trends will not stand and are trying to change the momentum.

India (2005-2006)

Pakistan (2012-2013)

Fertility rate

2.7

3.8

% of married women using a modern method of family planning

48.5

26.1

% of married women with unmet need for family planning

13.9

20.1

 

Source: India and Pakistan Demographic and Health Surveys

India is far ahead of Pakistan in terms of progress in family planning (see chart). The fertility rate (the average number of children a woman has in her lifetime) is 3.8 in India and 2.7 in Pakistan. In India, the contraceptive prevalence rate for modern methods is 48.5% (and will likely be higher than that when the 2014-15 Demographic and Health Survey comes out later this year) and 26.1% in Pakistan.

Dhanak and Surya networks are both programs of DKT International, a non-profit organization based in Washington, D.C. that makes family planning, reproductive health and HIV prevention products and services available to low-income populations through social marketing and social franchising. I was in Pakistan and India to visit both programs.

DKT’s Janani program, one of its oldest, works in Bihar, Jharkhand, Madhya Pradesh, Uttar Pradesh, Chhattisgarh, Assam and West Bengal providing these products and services through social franchising in Surya clinics (both Janani-owned and franchised clinics) and through social marketing in private sector outlets.

DKT Pakistan, one of DKT’s newest programs, has aggressively built up its network of midwife-owned and operated Dhanak clinics to 600 in only two years. It aims to double that, to 1,200, by the end of 2015. The clinics operate in all parts of Pakistan from the deserts of Sindh in the south to the snow-capped Himalayan peaks in the north.

The Surya and Dhanak social franchising networks are different in some ways (Dhanak clinics are owned by midwives; Surya clinics are owned by Janani or doctors), but they have more commonalities than differences. They both:

  • Focus intently on rural areas, which is appropriate given that their clientele are overwhelmingly rural (Pakistan is 65% rural and Bihar is 85% rural).
  • Observe franchising principles standard appearance, signage, advertising, etc.
  • Carry out regular quality assurance to ensure that all clinics meet and maintain high standards of quality.
  • Offer training and refresher training to ensure that their clinical staffs have the skills they need to give optimal health care to their clients.
  • Provide a full line of reproductive health services and products.

Several of the same obstacles to family planning came up in both countries pressure to have a lot of children and to have at least one male child. In some cases, the pressure is there because they cannot be sure if all of their children will survive. The pressure can come from the husband, the mother-in-law or other family members.

In my brief, unscientific visits, I was pleased to encounter several progressive husbands and mothers-in-law, who supported women’s desire to control the size of their families. I hope this evidence is more than anecdotal.

Almost 20 years ago, the study “Factors Affecting Contraceptive Use in Pakistan” revealed that “knowledge of a source and easy access to a service outlet are strongly related to contraceptive use for both urban and rural women, reinforcing the fact that the availability of and access to services are critical factors for raising the level of contraceptive use.”

That is still true to some extent and but programs such as DKT Pakistan and Janani and others like them are working hard to change the dynamic and bring contraception as close as possible to those who need it.

The Top 10 Global Health Stories of 2014

22nd Dec 2014

By David J. Olson

Ebola, the biggest global health story of the year, is one that no one could have predicted when the year dawned almost 12 months ago. It did something that few global health stories do: It entered the consciousness of the global public in an important way. Beyond Ebola, though, there was much to celebrate in 2014.

 

1.     Ebola: That one word represented not only the biggest global health story of the year, but one of the biggest stories of the year, of any type. As of Dec. 17, the World Health Organization (WHO) reported 18,603 cases and 6,915 deaths. Late in the year, incidence was declining in Liberia, slowing in Sierra Leone and “fluctuating” in Guinea. Sierra Leone surpassed Liberia as the country with the most reported cases. As I wrote here on Global Health TV last month, Ebola has made the definitive case for stronger health systems and health workers in developing countries.

 

2.     Remarkable Progress against Malaria: On Dec. 9, WHO announced that the number of people dying from malaria had fallen dramatically since 2000 and malaria cases are steadily declining. Between 2000 and 2013, the malaria mortality rate decreased by 47% worldwide and 54% in Africa, where about 90% of malaria deaths occur. Globally, an increasing number of countries are moving towards malaria elimination, and many regional groups are setting ambitious elimination targets, the most recent being a declaration to eliminate malaria from the Asia-Pacific region by 2030.

 

3.     And Equally Remarkable Progress for Children: The under-five mortality rate has declined by almost half since 1990, according to a report published by UNICEF in September, and the absolute number of under-five deaths was cut in half during the same period. In June, the governments of Ethiopia, India and the U.S., plus UNICEF and the Bill & Melinda Gates Foundation, hosted a summit to plan the end of preventable child and maternal deaths by 2035. USAID Administrator Raj Shah announced that USAID is realigning $2.9 billion of agency resources to save up to a half a million children from preventable deaths by 2015. Read more in my July blog here at Global Health TV.

 

4.     AIDS “Tipping Point” Finally Reached: Although it was underreported, we reached the long-anticipated tipping point of AIDS – the moment at which we put more people on AIDS treatment than the number of people who were newly infected. This doesn’t mean the end of AIDS but many people think it marks “the beginning of the end of AIDS.”

 

5.     Universal Health Coverage: 2014 seemed to be the moment for universal health coverage (UHC). Two years ago, the United National General Assembly unanimously endorsed UHC as an important step in the fight against health inequity. On Dec. 12, we marked the first-ever Universal Health Coverage Day. Since 2010, 80 countries have asked WHO for assistance in making UHC a reality, including India, whose new Narendra Modi government announced it is rolling out national health insurance by the end of the year. Here are some examples.

 

6.     A Terrible Year for Children: Despite the progress in Number 3, UNICEF declared 2014 a devastating year for children. “Children have been killed while studying in the classroom and while sleeping in their beds; they have been orphaned, kidnapped, tortured, recruited, raped and even sold as slaves,” said UNICEF Executive Director Anthony Lake. “Never in recent memory have so many children been subjected to such unspeakable brutality.”

 

7.     Strange Bedfellows in Global Health: It used to be that a donor would sit down with the ministry of health to work out the design and implementation of a new global health initiative with no significant involvement of other stakeholders. Nowadays, it’s widely recognized that more stakeholders need to be consulted — stakeholders as varied as the private sector, faith-based organizations, universities, research institutions, youth, women and community-based organizations. As I wrote here, “we need strange bedfellows engaging in unorthodox collaborations.” This started to happen more in 2014, and needs to be accelerated.

 

8.     Focus on Family Planning: 2014 marked two years since the breakthrough London Summit on Family Planning, which pledged to reach 120 million new women and girls with modern contraception by 2020. In December, Family Planning 2020 released its annual report, announcing that 8.4 million additional women and girls used modern contraception in 2013 as compared to 2012. The report notes that this accomplishment did not meet the goal of 9.4 million additional users but “is still a significant milestone.” In 2013, social marketing organizations delivered 70 million couple years of protection and expect to eventually reach as many as a quarter of those 120 million new users. The Bill & Melinda Gates continue to play a much-needed leadership role in all of this. “Melinda Gates and the BMGF jumped into family planning with two feet,” said IntraHealth President Pape Gaye.

 

9.     Still Neglected NCDs: Despite the 2011 United Nations High-Level Meeting on NCDs, non-communicable diseases are getting more attention but still almost no resources. NCDs should be a lot higher on this list than Number 9. The first paragraph of a new report by the Council on Foreign Relations, tells the story of our misplaced priorities well: “The gravest health threats facing low- and middle-income countries are not the plagues, parasites, and blights that dominate the news cycle and international relief efforts. They are the everyday diseases the international community understands and could address, but fails to take action against.”

 

10.  Global Development Lab: The Obama Administration announced that it is creating a Global Development Lab as part of the U.S. Agency for International Development to develop breakthrough ideas to combat hunger, disease and poverty. Ann Mei Chang, the Google executive brought in to head the new initiative says that to achieve the lab’s goal of saving the lives of 200 million people in five years, the lab will have to bet on some radical ideas.

 

 

Ebola Makes the Definitive Case for Health Workers And Strong Health Systems

25th Nov 2014

 By David J. Olson

Since I first wrote about Ebola here at Global Health TV two months ago, the number of Ebola deaths has more than doubled, to 5,459, and the number infected has reached 15,351, according to the World Health Organization. Ebola has caused countless angst and affliction, mostly in West Africa but also in Spain and the U.S.

 

But there is one good thing that Ebola has done: It has made the case for strengthening health systems and frontline health workers more effectively than we in global health have been able to do. It has shown that weaknesses in health systems in poorer countries can affect people in richer countries. It has made that case not only to the global health community, but to the entire world.

 

“Weaknesses in West Africa’s health systems do not affect just West Africa – they affect us all,” said Pape Gaye, president and CEO of IntraHealth International, in testimony to the U.S. Senate Appropriations Committee on Nov. 12. “Ebola, HIV and other viruses and infectious diseases do not respect borders. Globally, our countries’ health systems are interconnected, creating one global interdependent health system. Today, that system is woefully precarious.”

 

In his keynote address to the annual conference of the American Society for Tropical Medicine and Hygiene on Nov. 2, Bill Gates presented lessons we have learned about Ebola. In his opinion, the first and most basic lesson is: “We really should be investing in the primary health care systems of all countries, and in Africa in particular. When those systems are weak, it means our ability to understand what is happening and our capacity to respond is likewise weak.“

 

In the last five years, I’ve seen an increasing number of organizations like IntraHealth International, AMREF USA, PSI and the Frontline Health Workers Coalition do a great job of making this case. But little progress has been made in the places that need it most, like the countries most afflicted with Ebola, and it has not had much of an impact outside of the global health community. Ebola has changed that.

 

Blame is often leveled at donors who have tended to focus their health assistance on specific diseases like HIV, malaria and tuberculosis. Countries with high levels of these diseases, especially HIV, tended to attract greater support for their health systems, and this benefit often went beyond HIV/AIDS.

 

But countries with low rates of HIV, like most of West Africa, missed out on this health investment bonanza over the last decade, reported Guardian Health Editor Sarah Boseley. No such investment took place in Guinea, Liberia and Sierra Leone.

 

One hopes that this thinking is now starting to change as the Ebola crisis has exposed the fragility of health systems in developing countries and how this can threaten developed countries’ health.

 

The Frontline Health Workers Coalition is exploiting this new opportunity by presenting its recommendations to the U.S. Senate Appropriations Committee. “The Ebola virus disease epidemic in West Africa has highlighted the urgent need for increased support for frontline health workers and the systems that support them in the region and around the world,” begins the written testimony submitted on Nov. 12.

 

The Coalition believes it is no coincidence that the three countries primarily affected by Ebola have some of the lowest numbers of health workers per capita in the world – “less than three doctors, nurses or midwives per every 10,000 people before the Ebola epidemic even took hold, far less than the 22.8 per 10,000 ratio recommended by the World Health Organization to deliver basis health services.”

 

Others are also saying that more can be done.

 

“The United States can and should do more,” writes global health writer Nellie Bristol in the blog of the Center for Strategic and International Studies Global Health Policy Center. “These are not glamorous activities, and they have long been a difficult sell to Congress. They are hard to explain and quantify and lawmakers are under constant pressure to justify foreign aid to a deeply skeptical public. But the Ebola outbreak provides a glaring example of the need … Congress can act to send a strong message that health aid can be used more broadly and with a focus on long term results.”

 

Pape Gaye of IntraHealth has pointed out that the U.S. Agency for International Development already funds several projects to strengthen health systems but could do more, such as stipulate that a small portion of all its projects be invested in health systems strengthening.

 

Ethiopian Foreign Minister (and former Health Minister) Tedros Adhanom Ghebreyesus sees Ebola as an opportunity to build the primary health care systems. “Ebola could be prevented through simple disease prevention activities,” he told Devex in this interview. “Strong primary health systems are long overdue … If you have that kind of system, any outbreak can be detected easily and contained and information can flow through the system.”

 

Richard G. Marlink, a professor at the Harvard School of Public Health and head of Harvard’s AIDS Initiative, writes in the Global Post that we need to take an approach similar to the President’s Emergency Plan for AIDS Relief (PEPFAR) to build strong health care systems in the poorest countries of Africa.

 

“What’s needed now is a PEPFAR for African health at large, moving beyond the single-disease focus that is a hallmark of crisis management,” he wrote.

 

Ebola is a tragedy but it could be transformed into a strategy for building strong health systems and health workers that will be essential for dealing effectively with the next global health crisis that will surely come.

 

General ODA and Health Aid Are Up but Donors Still Not Meeting Targets

29th Oct 2014

By David J. Olson

After two years of declines, overseas development assistance (ODA) rebounded in 2013, but most donors have not met their commitments and are not sending a high enough proportion of their aid to the poorest countries, according to the ONE Campaign’s 2014 DATA Report.

 

Global health funding hit an all-time high of $31.3 billion in 2013, and funding for maternal, newborn and child health increased by nearly 18% between 2010 and 2011, reported the Institute for Health Metrics and Evaluation at the University of Washington in its annual report on global health financing.

 

And while aid donors are finally showing signs of improvement in meeting transparency commitments on that ODA, the majority – including the United States – is a long way from its commitment to adopt standards set by the Aid Transparency Index 2014.

 

These were some of the headlines coming out of two reports released this month, but very much overshadowed by the justified focus on Ebola, as well as an earlier report on global health financing released in April.

 

ONE’s DATA Report shows that although ODA increased in 2013 (the U.K. was responsible for most of that), donors’ total aid represented only 0.29% of their collective Gross National Income (GNI) – far below the UN target of 0.7%. In fact, only five of the 23 countries in the OECD Development Assistance Committee achieved 0.7% — Norway, Sweden, Luxembourg, Demark and the U.K. (for the first time). The U.S. came in at 0.19%, lower than all but eight countries.

 

To be fair, the United States remains the largest bilateral aid donor in the world, having provided $31.4 billion in 2013. However, a decreasing percentage of its aid has gone to countries that need it to the most, reports ONE. “Last year – for the first time since 2005 – the U.S. is estimated to have cut its aid flows to sub-Saharan Africa by 1.4%,” said the DATA Report.

 

Moreover, donors as a whole spent just 0.09% of their collective GNI on aid to least developed countries in 2012, well below the UN target of 0.15-0.20%. LDCs remain highly dependent on aid.

 

The DATA Report also weighed in on the extent to which African nations are meeting their own health needs. In 2001, African leaders met in Abuja, Nigeria and pledged to allocate 15% of their national budgets to health. Between 2010 and 2012, just six of the 43 countries for which there was data available spent 15% of their budgets on health: Rwanda (23%), Malawi (18%), Swaziland (17%), Liberia (16.5%), Zambia (16%) and Togo (15%). Six additional countries – Lesotho, Namibia, Madagascar, Burundi, Burkina Faso and the Democratic Republic Congo – came close, with allocations greater than 13%. However, 18 countries did not reach even the 10% level.

 

While the Abuja target provides a useful metric, many global health experts consider per capita spending to be a better measure of a country’s capacity to meet its citizens’ health needs. That measure shows a very different picture, with eight countries providing health expenditures per capita in excess of $185  – Equatorial Guinea, Seychelles, South Africa, Namibia, Botswana, Mauritius, Gabon and Swaziland. Five of the six countries which met the Abuja target are nowhere near the top of the per capita list (only Swaziland is high on both lists). Twenty nations did not even spend $20 per capita for their citizens’ health.

 

Financing Global Health 2013: Transition in an Age of Austerity shows that although development assistance for health (DAH) reached an all-time high of $31.3 billion in 2013, the 4% growth from 2012 to 2013 “falls short of the rapid rates seen over 2001-2010, which topped 10% annually.

 

The report shows that non-communicable diseases (NCDs) and tobacco control received little funding, especially when one considers the substantial burden of disease associated with NCDs. For the first time, the report measured funding for tobacco control, which totaled $68 million in 2011. In comparison, funding for HIV/AIDS (the health issue receiving the most funding in 2011) was 113 times as large as the funding for tobacco control.

 

The Aid Transparency Initiative 2014 shows that overall, aid donors are showing signs of improve transparency but most are still a long way from meeting their commitments to publish using Aid Transparency Initiative standards.

 

The United Nations Development Program, the Department for International Development (of the U.K.), the Millennium Challenge Corporation (of the U.S.) and GAVI were found to be the four most transparent donors. The Global Fund to Fight AIDS, TB and Malaria was Number 10.

 

However, U.S. agencies were much lower on the list: The U.S. President’s Emergency Plan for AIDS Relief (Number 30) and the U.S. Agency for International Development (31) were rated on the low side of “fair” and the U.S. Department of State (32) was rated as “poor,” according to the Aid Transparency Index 2014. Some good news: PEPFAR showed the greatest improvement among the U.S. agencies and PEPFAR Coordinator Deborah Birx says that PEPFAR is committed to strengthening transparency further.

 

With one year before the expiration of the Millennium Development Goals, there has never been a better time for donors to truly meet their aid commitments and meet them in a transparent way.

 

 

 

 

Focus on Ebola Should Not Compromise Efforts Against Other Diseases That Kill More People

23rd Sep 2014

By David J. Olson

Ebola is a terrible disease that has already infected 5,335 people and killed 2,630 as of Sept. 14, according to the World Health Organization (WHO), and threatens to kill many more thousands before its rampage of destruction is slowed down or stopped. WHO designated it as a global emergency on Aug. 8.

 

“This Ebola epidemic is the largest and most severe and most complex we have ever seen in the nearly 40-year history of this disease,” said Margaret Chan, director-general of the WHO. “This is a global threat that requires global coordination to get it done. We can and we will bring the Ebola epidemic under control.”

 

Yet another of its terrible legacies may be that it will distract attention and resources from other diseases that are killing far more people.

 

In the three countries where it has been most virulent Guinea, Liberia and Sierra Leone AIDS, malaria and tuberculosis kills many more people than Ebola. Here are the numbers of people those three diseases have killed in those three countries in one year:

 

Tuberculosis: 16,400 (WHO)

AIDS: 10,100 (UNAIDS)

Malaria: 6,315 (WHO)

 

The ten leading causes of death in low-income countries in 2012, according to the WHO, were lower respiratory infections, HIV/AIDS, diarrheal diseases, stroke, ischaemic heart disease, malaria, preterm birth complications, tuberculosis, birth asphyxia and birth trauma, and protein energy malnutrition.

 

Global health journalist Sam Loewenberg tweeted that in Uganda alone, diarrhea kills almost 20,000 children every year. That’s the number of people the WHO thinks Ebola may eventually claim.

 

Earlier this month, Columbia University professor Chris Blattman tweeted that “Ebola is the Kardashian of diseases,” that it steals attention away from other global health priorities and that malaria, TB and HIV are what matters. [Note: For those who don’t know what a Kardashian is, it roughly translates to being famous for no substantive reason.]

 

He wrote a blog entitled “Does Chicken Little have Ebola?” and said this about Liberia: “… the fearful and overblown coverage will do more damage in the long run as businesses and NGOs pull out, or deals in the future never get done. I’d venture a guess that shaving a percentage point off GDP for the next few years will lead to more preventable deaths than the [Ebola] disease will in the end. This is disastrous for the country and it doesn’t help when organizations like MSF say it is ‘spiraling out of control.’”

 

Others strongly disagree.

 

I do not think that Ebola is as irrelevant as the Khardasians but I do worry that a singled-mind obsession with it could compromise other global health efforts. Indeed, that may be already happening.

 

Christine Sow, executive director of the Global Health Council, worries that Congress will use money already allocated for other global health concerns to pay for new funding to fight Ebola.

 

“Redirecting funds would be a shortsighted strategy to respond to a rapidly growing crisis,” she wrote in the Washington Post. “The U.S. government must provide funding and leadership commensurate with the Ebola emergency while maintaining the country’s place as a global leader in the fight on child and maternal mortality and HIV/AIDS.”

 

I’m not suggesting that we should not do everything possible to eradicate the scourge of Ebola. We should. But I am urging that we not forget those endemic, preventable and “mundane” diseases that have been around so long that we risk taking them for granted.

 

 

Are Donors Adequately Funding Faith Groups For Maximum Impact In Global Health?

26th Aug 2014

By David J. Olson

Last November, at an event associated with the International Conference on Family Planning in Addis Ababa, Ethiopia, I was struck by a public comment from a representative of the U.S. Agency for International Development (USAID): “With almost 90% of people globally professing a faith, it doesn’t make sense to do family planning without the faith community.”

 

I was bowled over by this statement. I checked up on the claim, and found that, according to the Pew Research Center, 84% of the 2010 world population of 6.9 billion is considered “religiously affiliated.”

 

So the point was valid, and I would go even further: We in global development should be partnering more with the faith community in all areas of global health. After all, if the faith community can work on family planning – fraught with all of its social, cultural and religious baggage – it should also be able to work effectively on less controversial issues like malaria, diarrhea, water and sanitation. Especially in places like Africa where people have a high level of confidence in their religious institutions.

 

Ray Martin, who is stepping down as executive director of Christian Connections for International Health (CCIH) August 31 after 14 years on the job, knows as much as anyone about this issue (Full disclosure: I serve on the board of CCIH).

 

“While it is gratifying to me over a five-decade career in global health to observe that the development community has discovered faith-based organizations (FBOs), it still hasn’t sufficiently appreciated their potential and the potential of religious leaders to contribute to ambitious goals in global health and development.”

 

For years, donors like USAID have been funding large faith groups like World Vision and Catholic Relief Services. But in the last two decades, a unique and distinct category of organizations now called FBOs began to take shape.

 

“FBOs have a particular identity that they didn’t have in the past in the development community,” said Martin. “And some secular people appreciate that the faith aspect itself can add a special ingredient to the development dynamic, often positive, though not always, as in the early days of AIDS.”

 

He said that there is a growing willingness to take FBOs and religious leaders seriously but there is still a long way to go. Among major donors, he says, USAID is progressive in this respect and DFID [the UK’s Department for International Development] to some degree. United Nation agencies and the World Bank are less so although “the picture isn’t all bleak.”

 

Martin says that some people in the FBO world argue that fairness would dictate that donors provide considerably more resources to FBOs. So if FBOs in Africa provide 40% of health services, as they do in some countries, then FBOs should get 40% of the grants, or something close to it.

 

“I reject that argument,” said Martin. “I don’t think FBOs can make a compelling argument that they deserve any particular proportion of donor dollars. What I think we should argue is that the overall global health and development community need to embrace FBOs much more seriously than they have been willing to do thus far, if they have any serious hope of attaining the ambitious objectives they have articulated for the next generation.”

 

In fact, we do not know how much health care is delivered by FBOs in developing countries, and it varies greatly from country to country.

 

“This information is not systematic or comprehensive and much is difficult to find,” according to this excellent 2013 policy brief written by Katherine Marshall and Lynn Aylward of the World Faiths Development Dialogue and the Berkley Center for Religion, Peace & World Affairs at Georgetown University and the longer 2012 report which it summarizes. “Faith communities and organizations are important healthcare providers throughout Africa; while their exact market share is debated, it is large.”

 

The brief reports mixed findings on the amount of funding FBOs are receiving in global health.

 

While there are examples of collaboration between the global health community and FBOs, such as with UNICEF and UNFPA, FBOs “received only small shares of funding from some large health organizations. Estimates put the funds disbursed by the Global Fund to Fight AIDS, TB and Malaria directly to FBOs in its first eight funding rounds at only 3 percent.” On the other hand, large FBOs like World Vision and Catholic Relief Services receive significant amounts of USAID funding.

 

USAID and the World Bank both told me they do not quantify their funding to FBOs. However, both of them are trying to make it easier for FBOs to access their funding.

 

“We do not distinguish between funding for faith-based and secular organizations, but with a commitment to reaching the poorest of the poor, we recognize our faith-based partners are at the forefront of turning a new model of development into action, “said USAID Administrator Raj Shah.

 

“We want the best solutions to development challenges, wherever they exist,” said Adam Taylor, an ordained Baptist pastor who took over as the lead for the World Bank’s Faith-Based Initiative a year ago. “If they are developed by faith-based organizations, that’s great, but there’s no inherent advantage that FBOs have over secular organizations. It’s really all about impact.”

 

Taylor said that some development agencies used to have a bias against FBOs, viewing them as overly patriarchal and sectarian. “The good news is that a lot of those misgivings and fears have dissipated,” he said. “I think development institutions, including the World Bank, have turned the corner. It’s now much more about how do we partner in a way that’s going to reach the poorest and most marginalized, that’s going to stretch the dollar and have the most impact.”

 

USAID Administrator Shah says that since USAID’s founding more than 50 years ago, collaboration with faith and community organizations has been integral to USAID’s mission.

 

“Over the past decade, we have seen how this [faith-based] approach has delivered tremendous results,” said Shah. “We’ve helped immunize 440 million children; cut the rate of children dying from malaria in half; and nearly eliminated the transmission of HIV/AIDS from mothers to their children. These efforts have helped reduce child mortality by a half, and they would not have been possible without the tireless efforts of our faith-based partners.”

 

And Martin points out that with sustainability such a concern, one can make the point that religious institutions “will certainly continue regardless of economic growth, conflict or whatever, so investing in them will likely have a more enduring impact than investing in the ‘Beltway Bandit’ types of institutions that get so much of the donor dollars.”

 

But to forge truly effective donor-FBO partnerships, there must be change on both sides, said Martin:

 

“It is incumbent on the big donors who are talking about an AIDS-free generation  and eliminating preventable child death to revise their procurement mechanisms in order to reach faith- and community-based organizations. And FBOs will be taken more seriously only if we are more rigorous in our monitoring and evaluation, and more diligent about documenting our work.”

 

 

 

New Momentum to End Preventable Child and Maternal Deaths by 2035

22nd Jul 2014

By David J. Olson

In June 2012, the governments of Ethiopia, India and the U.S., in collaboration with UNICEF, hosted the “Child Survival: Call to Action,” designed to focus the disparate priorities of the global health world into a single, achievable goal of ending preventable child deaths by 2035.

 

Much progress has been made in the last two decades – the total number of child deaths fell from 12.6 million in 1990 to 6.6 million in 2012. And maternal mortality worldwide dropped by 45% between 1990 and 2013, according to the World Health Organization, from 523,000 deaths in 1990 to 289,000 in 2013.

 

However, there are still unacceptably high levels of maternal and child mortality, as shown in this terrific infographic, and the status quo will not get us where we need to be the elimination of preventable child and maternal deaths by 2035.

 

We are not making particularly good progress towards Millennium Development Goals 4 and 5 on child and maternal health, which expire in 2015. Out of the 24 high-priority countries on which the U.S. Agency for International Development focuses, only six countries have achieved MDG 4 (Bangladesh, Malawi, Nepal, Liberia, Tanzania and Ethiopia) and only two have achieved MDG 5 (Rwanda and Nepal).

 

So I was encouraged to participate in another high level event, “Acting on the Call: Ending preventable child and maternal deaths,” organized by USAID, the Bill & Melinda Gates Foundation, UNICEF and the governments of Ethiopia and India at USAID headquarters in Washington, D.C. on June 25.

 

USAID Administrator opened the day-long event by announcing that USAID is realigning $2.9 billion of agency resources to save up to a half a million children from preventable deaths by the end of 2015 by refocusing resources on high-impact programs. USAID has already ended global health funding in 26 countries and is now focusing all its attention on 24 countries primarily in sub-Saharan Africa and South Asia that account for 70% of maternal and child deaths and half of the unmet need for family planning.

 

“We are here today because for the first time in our history, we stand within reach of a world that was simply unimaginable for so long: a world without child and maternal death,” said Shah in his remarks. “We know how to reach every woman and every child with simple, low-cost medicines and interventions that will help all of them survive and thrive.”

“Right now, we are partnering with engines of innovation corporations, foundations, NGOs, faith-based communities, entrepreneurs and local leadersto solve one of the greatest development challenges: ending extreme poverty and build thriving, resilient societies. We know that, by working with the global community, we can end preventable child and maternal deaths, which is critical to our own national security, economic prosperity and moral leadership.”

 

World Bank President Jim Kim, who also appeared, said there will be more than enough resources to end preventable maternal and child deaths. “A lack of resources should not be an excuse,” he said. He also urged more focus on domestic resources within developing countries, which is already happening in HIV/AIDS.

 

But what will it take to achieve further success in maternal and child health? The Partnership for Maternal, Newborn & Child Health looked at more than 250 health and development indicators for 144 low- and middle-income countries and found ten countries “punching well above their spending weight”: Bangladesh, Cambodia, China, Egypt, Ethiopia, Laos, Nepal, Peru, Rwanda and Vietnam. These countries are expected to achieve MDGs 4 and 5 ahead of comparable countries.

 

On The Lancet Global Health Blog, Carole Presern, director of PMNCH, wrote that they found no standard formula for success but they did find that these 10 countries all acted in three main areas to reduce maternal and child mortality.

 

  • They invested across various sectors, not just health.
  • They adopted strategies to make the best use of available resources.
  • They used up-to-date evidence to support decision-making and accountability for results.

 

I was pleased to see a Republican make the case for family planning as a tool for reducing maternal and child mortality. A video was screened showing former Senate Majority Leader Bill Frist promoting family planning.

 

“There are over 222 million women today who want to delay pregnancy but are not using family planning,” he says. “This is not a partisan issue. It’s a humanitarian issue. It comes down to being the right thing to do, scientifically demonstrated, and that is non-partisan. By enabling women to engage in family planning, we know that we can reduce overall maternal deaths by as much as 30% and neonatal and child deaths by as much as 25%.”

 

It is critical to keep maternal and child health a bipartisan issue, as with HIV/AIDS. A reception on Capitol Hill that evening provided some evidence that that might actually be possible. A highly bipartisan group of members of Congress spoke to the crowd, ranging from conservative stalwarts like Sens. Lindsey Graham and Rep. Chris Smith to liberals like Sen. Chris Coons and Rep. Betty McCollum. The fact that such strange bedfellow can line up behind this issue perhaps the only issue they can all agree on gives me hope that perhaps we can achieve such a monumental goal by 2035.

 

What Are the Keys to Family Planning Success in Africa?

24th Jun 2014

By David J. Olson

In the last 20 years, Ethiopia has emerged as a family planning powerhouse. In Studies in Family Planning, I reported that, from 1990 to 2011, modern contraceptive use increased ninefold, from 2.9% to 27.3%, and the total fertility rate (the average number of children born to a woman in her lifetime) dropped from 7.0 to 4.8.

Now Ethiopia’s reputation has been further burnished by the results of a report released May 27th by Performance Monitoring and Accountability 2020 (PMA2020) that show an increase in the use of modern contraception from 27.3% in 2011 to 33.3% in 2014 and a drop in the fertility rate from 4.8% to 4.4%.

Four Central Determinants of Success

This prompts the question: What are the factors that lead to family planning success? And what are the factors that stall such progress? Our article in Studies in Family Planning identified four determinants of success in Ethiopia. I suspect that many, if not all of these, ring true elsewhere in sub-Saharan Africa:

Political Will:  Although not necessarily indispensable, success is much harder to achieve when political will is weak or absent. In setting its development policies, the Government of Ethiopia focused on demographic factors, recognizing population growth as one of the main obstacles to addressing poverty, and consistently set ambitious goals for family planning, and it sustained that support over time.

Generous Donor Support: From 2000 to 2010, Ethiopia was the largest recipient of international family planning assistance in sub-Saharan Africa. International donors have provided continuous support for purchasing products, strengthening government capacity and improving policy, research and training.

Nongovernmental Organizations and Public-Private Partnerships:  A number of national and international NGOs have supported government’s efforts and employed strategies such as social marketing, behavior change communications and mobile clinics as ways of providing access to and stimulating demand for contraceptives in low-resource settings.

Health Extension Program: The government’s flagship health program played a major role in the provision of contraceptives, especially in the rural areas, where 83% of its people live. The government invested in a network of 38,000 health extension workers based at 17,000 health posts to bring education and contraceptive products and services to rural areas that previously lacked trained health personnel and high-quality facilities.

“What is remarkable about Ethiopia’s success is that it has been achieved through improving access not just to the urban and wealthier segments of the population, but among rural and poorer segments a testament to outreach into rural and peri-urban areas and the reach of the health extension workers,” said Scott Radloff, director of PMA2020 and senior scientist at the Bill & Melinda Gates Institute for Population and Reproductive Health.

Political Will Plays a Key Role

In a 2013 research brief, “Drivers of Progress in Increasing Contraceptive Use in sub-Saharan Africa,” the African Institute for Development Policy posited that political will is “the most critical enabler” of family planning progress, and identified five countries as having developed the political will necessary to expand family planning Rwanda, Ethiopia, Malawi, Tanzania and Kenya.

“Rwanda stands out with strong leadership by the President who openly supports and promotes family planning as a development tool,” according to AFIDEP. “This has been institutionalized in Rwanda, and traverses all levels of leadership and government.”

In the other four countries, says AFIDEP, political will manifests itself at the Ministry of Health (and, in the case of Kenya, Ministry of Planning) and the heads of state are not vocal about family planning.

What Causes Family Planning to Stall?

However, family planning progress has stalled in both Kenya and Tanzania over the last 20 years.

Kenya’s fertility rate hit 5.4 in 1993 but has not changed much since then, and now stands at 4.6, according to the 2008-09 Kenya Demographic & Health Survey. The Daily Nation, Kenya’s largest circulation newspaper, reported on this last month in an article entitled “Five children per woman: How Kenya lost the family planning battle.” A similar phenomenon occurred in Tanzania: After getting its fertility rate down to 5.8 in 1996, it barely moved. In 2010, it was estimated at 5.4.

In its research brief, AFIDEP attributed the stalled progress in Kenya to “the shift in top leadership prioritization of family planning, which was compounded by the shift in donor priority and funding” towards HIV/AIDS and away from family planning.  In addition, Tanzania’s program was adversely affected by the decentralization of the health sector during that period.

Radloff added that the commitments in Kenya and Tanzania among both donors and governments “have been more volatile and tepid, accounting largely for the stalls that we have seen there.”

The main take-away from the stalled progress in Kenya and Tanzania, according to AFIDEP, is that sustained efforts are required from all stakeholders to ensure that funding and technical inputs for improving the quality and outreach of FP services is maintained.

AFIDEP says both countries have gone a long way in addressing these challenges and revitalizing their FP programs. Radloff agrees that both countries are in “an up-tick period in terms of revitalization but still have a ways to go” before they match Ethiopia’s prioritization of family planning. PMA2020 expects to have results for Kenya on the PMA2020 website in July.

Lessons Learned in Ethiopia

Our article in Studies in Family Planning highlighted lessons learned in Ethiopia that may help other countries emulate the Ethiopian success including:

  1. -Positioning of population and family planning at the center of development is critical.
  2. -More efforts must be made to diversify the contraceptive mix. The success in Ethiopia depends heavily on injectables and, to a lesser extent, implants.
  3. -The presence of a large and active social marketing program can contribute to higher contraceptive prevalence.
  4. -African countries should follow Ethiopia’s example of investing its own funds in family planning.
  5. -More progress must be made in integrating the response to HIV/AIDS with family planning.
  6. -Governments should fully engage the broad civil society – including NGOS, the private sector and faith-based organizations – so they can each bring their own unique contribution to family planning success.
  7. -The private sector should be better exploited. For example, governments could license more private pharmacies, drug stories and clinics; permit the sale of more reproductive health drugs through the pharmaceutical network; and liberalize the advertising of contraceptives.

 

For the whole of sub-Saharan Africa, the fertility rate is 5.2 and the CPR for modern methods is 21%. Those numbers could be dramatically improved if more countries followed the examples of Ethiopia, Rwanda and Malawi.

 

Kenya Quietly Takes Public Health Approach With HIV Most At-Risk Groups

27th May 2014

By David J. Olson

 

NAIROBI and KISUMU, Kenya Anti-gay legislation recently signed into law in Uganda and Nigeria has alarmed organizations implementing HIV prevention in Africa, fearing that such laws will further stigmatize and marginalize at-risk populations already hard to reach with health services.

So when I traveled to Kenya this month to interview men who have sex with men (MSM), injecting drug users (IDUs), and people working in programs trying to help them supported by the International HIV/AIDS Alliance, I wondered whether I would encounter “the next Uganda” in gay rights. I did not, but what I did find surprised me.

Certainly there is a great deal of stigma and discrimination toward gay people in Kenya, everybody told me. I already knew this from 2012, when I was working on abortion in Kenya and a health provider told me that abortion was the most stigmatized issue in Kenya, except for homosexuality.

But the Kenyan government has quietly adopted mostly sensible and evidence-based policies towards both MSM and IDUs, according to the many HIV, MSM and IDU activists and implementers with whom I spoke.

So perhaps it should not be surprising that serious progress is being made against HIV in Kenya: HIV prevalence has dropped from 7.2% in 2007 to 5.6% in 2012, according to the Kenya AIDS Indicator Survey 2012. UNAIDS says the number of new infections declined by 32% between 2001 and 2011. Of new infections in Kenya, 15% come from MSM and prisoners and 4% come from IDUs, according to the National AIDS and STI Control Program.

“If you look at the government and the support it gives to the drop-in centers [for MSM and sex workers], you see that Kenya is doing better than other countries [in terms of its approach to most at-risk groups],” according to Teresa Watetu Maina, who runs such a drop-in center just outside Nairobi. At that center, government provides condoms, lubricants and technical assistance.

That program even collaborates with the police, although that is challenging because of constant reassignments and transfers. “It has been hard work,” said Watetu Maina. “You go the police, they buy in, you have a very good commanding officer and then he’s transferred. You have to go back and start the work all over again.”

Earlier this year, an anti-gay bill, like the one in Uganda, was introduced in Parliament.

“I know several people who lobbied a few members of Parliament to make them understand what the repercussions of having such a law in Kenya would be from a public health perspective,” said Jack Ndegwa of the Kenya AIDS NGO Consortium (KANCO), which implements MSM and IDU programs for the Alliance. “I am so grateful to the Ministry of Health that came out with a very comprehensive statement, saying the law was likely to have very negative health repercussions for key populations.”

The bill has not gone anywhere and, for the moment, is no longer being discussed.

The government’s evidence-based approach is not limited to MSM; it is also being applied to HIV prevention with IDUs.

In Muthurwa, a poor area of central Nairobi, I attended an unusual meeting between the local administration and a dozen IDUs.

“Nowadays, we don’t want to arrest you for using drugs, we want to help you overcome drugs,” Chief Rose Ayere told the drug users. “Use condoms. Get tested. If you have TB, there is a clinic in town. Go for early treatment so we don’t lose you to TB. If you are infected with HIV, the government has ARVs. It is free and you can take it in privacy. To take ARVs, you need good nutrition. NOSET (the Nairobi Outreach Services Trust, an implementing organization of the Alliance) can help you with that.”

If Chief Ayere sounded more like a public health expert than a government bureaucrat, it is because of a project called Community Action on Harm Reduction (CAHR), the first harm reduction program in Kenya, implemented by KANCO in Nairobi and the Coastal Region with support from the Alliance.

Chief Ayere told me that before the advent of CAHR, she used to arrest IDUs. “We didn’t know that IDUs are sick people who need special treatment and attention. Through training and facilitation by NOSET our mindset has changed and we became partners in the harm reduction program. These people need protection, not harassment, by security agencies in order to undergo treatment and reform.”

Now Chief Ayere is on a campaign to convince other chiefs to take a similar approach. She believes the number of HIV infections has dropped as a result. In July, CAHR expects to start a methadone program the first such program in Kenya to help IDUs manage the harmful consequences of drug use. A new publication of UNAIDS shows that harm reduction programs can significantly reduce HIV.

Even a police raid on the offices of Men Against AIDS Youth Group (MAAYGO), a men’s health and advocacy organization in Kisumu, last month provided an advocacy opportunity. MAAYGO used subsequent meetings with police and local authorities to educate them on how HIV prevention with MSM can help bring down the 15.1% HIV prevalence in Nyanza Province, the highest in all of Kenya. At the time of my visit, MAAYGO had returned to its MSM work from a new office.

Over and over again, I heard that on MSM and IDU issues, government is part of the solution and the main impediments are media and the mainstream churches.

Kenyan media consistently misreports, exaggerates and sensationalizes both of these issues in negative and irresponsible ways, program implementers say.

However, the role of churches is mixed. “The big churches, like Anglicans, Catholics and Seventh Day Adventists, are very much against us,” according to Kennedy Otieno of MAAYGO. “But the reformed and redeemed churches, the Peacemakers and the Quakers are very much supportive and will accept gay men in their congregations.”

People told me that overall, stigma from the general population is the greatest challenge for preventing HIV infection among MSM.

“Government has to play a stronger role in explaining to the public why MSM work is important,” said Otieno. This was the strongest criticism I heard of the government’s approach to most at-risk populations. But Otieno also thought government was playing a constructive role.

The rest of Africa has a lot to learn from Kenya in terms of responding to the needs of its most at-risk groups and in preventing HIV infections.

Social Enterprise for Health, Brazilian Style

27th Apr 2014

By David J. Olson

 

RIO DE JANEIRO, Brazil One is poised to become the condom market leader in Brazil, with 40 variants in its Prudence condom line. Its newest offering features the flavor and scent of caipirinha, the iconic Brazilian cocktail made from cachaça, lime and sugar. DKT believes it prevented over 9,000 HIV infections in 2013.

Another rescues the poorest and unhealthiest children from the urban slums of Rio de Janeiro, Sâo Paulo and other cities, and nurses them – and their families – back to health.  Since its creation, an estimated 50,000 people have benefitted from its work.

They are very different global health organizations, with very different operating models, but both call themselves social enterprises, Brazilian style, and both were created in 1991.

Brazil has become a kind of hub of the social enterprise world. In 2012, the Social Enterprise World Forum was held there. And I’m reading more articles, like this one, which claims that social enterprise is becoming the norm, “a really valid option proposed for anyone wanting to start or grow a business in Brazil.”

So in March, on a trip to Brazil, I visited both organizations to find out what brand of social enterprise they are.

 

Saúde Criança

Last year, I wrote about this organization (Saúde Criança means “child health”) founded by Dr. Vera Cordeiro in Rio de Janeiro.  It has developed a unique methodology that attempts to break the devastating cycle of disease-hospitalization-discharge-misery-disease experienced by many young children in the favelas (slums) of Brazil.

Saúde Criança identifies children and their families living below the poverty line. They are interviewed and assessed by Saúde Criança. Based on this information, a “family action plan” is developed for each family with objectives and indicators in the areas of health, citizenship, housing, education and income generation. To tackle these five areas, the program offers direct assistance, technical support, professional training, support programs and citizenship.

It is obvious that Saúde Criança produces short-term benefits for the family including improved health, an increase in income and better housing. But it was not known whether these effects were ephemeral or sustainable until last year when Georgetown University conducted the first rigorous evaluation of Saúde Criança. The evaluation found large and sustained gains across the five themes of Saúde Criança’s approach including a 90 percent decrease in hospitalization and a near-doubling of household income.

Saúde Criança now has 10 organizations in its social franchise network and another 11 using its methodology. Belo Horizonte, one of the largest cities in Brazil, has adopted its methodology and made it public policy. Dr. Cordeiro believes its methodology can be adapted to other countries in South America and elsewhere.

“Saúde Criança has now reached the point where the spread of its approach is gaining momentum,” said Bill Drayton, president of Ashoka. “This is the arc of the world’s truly excellent social entrepreneurs.”

Saúde Criança is dependent on its diversified funding coming from Brazilian and international companies, social entrepreneur organizations and individual donations but has a plan to sell its consultancy services to generate revenues and become more financially self-sufficient.

 

DKT Brazil

In its 23 years of existence, DKT Brazil has transformed itself from a charity entirely dependent on international donors to a social enterprise dependent only on its own marketing savvy.

When DKT Brazil was launched in 1991 as a condom social marketing organization, it received major funding from the U.S. Agency for International Development and other donors. But it was forced to become financially sustainable in 2003 when it lost its USAID funding.

Today, it is 100% financially sustainable. All of its products make money, and yet all of them are also within the contraceptive affordability index, which dictates that the cost of contraception should be less than 1% of a family’s annual income. In fact, its cheapest condom is only 0.22%. Even its most expensive brand does not reach 0.5%.

I first reported on DKT Brazil in an article on their ground-breaking efforts to use sexy advertising to sell condoms. They know this works as their share of the Brazilian condom market has increased to 21% in 2012. The new caipirinha condom is only the latest in a long line of flavored, scented and specialty condoms.

In 2013, DKT Brazil apparently became the first company to sponsor Carnaval for a social purpose.

Daniel Marun, country manager of DKT Brazil, based in Sâo Paulo, has a simple definition of social enterprise: “ Having a sustainable social impact without depending on anyone else.”

Clearly, DKT Brazil has achieved that goal, and even generated funds to start a new social marketing program in Mozambique. Furthermore, the approach has been shown to be replicable elsewhere, as DKT programs including Indonesia, Philippines and Turkey have already achieved financial sustainability.

Saúde Criança and DKT Brazil are very different types of social enterprises. Although neither gets funding from traditional donors, DKT Brazil has already achieved financial sustainability; Saúde Criança has a ways to go before it achieves that goal. But both can serve as useful models of social enterprise for other organizations in Brazil and other countries around the world.

Tuberculosis Finally Catching Up to 21st Century

24th Mar 2014

By David J. Olson

Tuberculosis (TB) treatment, which had been lost in a time warp for a century, seems to be finally joining the 21st century.

Until recently, there were no new TB drugs on the market in half a century, little progress in the treatment of multidrug-resistant (MDR) and extensively drug-resistant (XDR) forms of TB and virtually nothing new on pediatric TB, according to David Greeley, the president and CEO of Accordia Global Health Foundation, who previously worked for the TB Alliance. The current vaccine, developed more than a century ago, is largely ineffective, he said. TB diagnostics were ancient, too, as is TB itself, which has been around since 4,000 B.C. Current treatment was cheap and sometimes effective but took a long time and misses a lot of people  (like children, and MDR and XDR patients).

Which is why the Stop TB Partnership has made those missing people the theme of this year’s World TB Day on March 24: “Reach the 3 Million.” That’s the number of TB patients the World Health Organization (WHO) estimates are “missed” by public health systems out of the 8.6 million who fall ill of TB each year.  Many of those 3 million live in the world’s poorest, most vulnerable communities and include groups such as migrants, miners, drug users and sex workers. Over 95% of TB deaths occur in low- and middle-income countries. India and China are the countries with the most TB patients.

But much is changing for the better: The number of people falling ill from TB each year has declined for the last decade, albeit slowly, which means that the world has already achieved the Millennium Development Goal to reverse the spread of TB. This week, The Lancet published research that China has halved its TB prevalence in 20 years.

“I’m much more optimistic than I was five or ten years ago, “ Dr. Mario Raviglione, director of the Global Tuberculosis Program at WHO, told me this week. Dr. Raviglione gave three reasons for his optimism:

  • New tools, like “Gene Xpert,” a rapid molecular diagnostic test, which greatly improves the detection of TB.
  • Two new drugs, the first in half a century. They are limited to MDR-TB for the moment but could be expanded to normal TB if funding is increased.
  • A new push for universal health coverage. “The implication of this on TB is major,” said Dr. Raviglione. “TB is a disease of poverty. Pretending that we can control it without addressing the issue of the cost to the patient and the loss of income during the treatment period is simply foolish. The global push for universal health coverage is a unique opportunity to address TB.”

And now there is evidence that we may be on the verge of a major advance in TB control. Last week, Colorado State University research revealed that even the most intractable cases of TB might be effectively treated with a new drug cocktail combining conventional antibiotics and nontoxic compounds that mimic those found in some sea sponges.

 

“It’s certainly one of the most exciting ideas that I’ve heard for a long time,” said Dr. Raviglione. “It’s addressing probably the Number 1 crucial point about TB: If people discover how to deal with persisting organisms – what some call latent infection – then we probably will have a solution TB. I don’t dare to call it a paradigm shift. But it’s certainly something that could become a paradigm shift.”

“We need to push TB treatment off this plateau it’s been on for too many years,” said Greeley. “New drugs that can treat TB and drug-resistant TB more quickly, simply and cost-effectively are urgently needed.”

TB is second only to AIDS among infectious diseases and kills twice as many people as malaria. In 2012, 8.6 million people fell ill from TB and 1.3 million died of it, according to the WHO Fact Sheet on TB. While global death rates from some of the biggest infectious disease killers have dropped markedly in recent years, mortality rates from TB have been the same, with 1.5 to 2 million people dying each year from the curable disease.

In addition to the 3 million people missing from the system, Dr. Raviglione sees three other major issues on World TB Day 2014:

  • MDR-TB: Fortunately, 95% of TB cases in the world are not MDR or XDR. But there are pockets – such as Belarus, Ukraine and Uzbekistan – where up to one third of TB cases are MDR. These cases are extremely difficult to diagnose and treat.
  • TB associated with HIV/AIDS: TB is a leading killer of people living with HIV, causing one quarter of all deaths. 75% of HIV-TB co-infections are in Africa. There has been significant progress in this area in the last 6-7 years, said Dr. Raviglione. “There is no reason why only 50% of people co-infected with TB and HIV are receiving anti-retroviral drugs,” he said. “It should be 100%.”
  • Resources: Around $5-6 billion is spent on TB each year even though WHO believes that $8 billion should be spent, leaving a gap of $1.5-2 billion, said Dr. Raviglione. Unlike the response to AIDS and malaria, where international donors are carrying the load in most countries, 80% of the funding for TB comes from the recipient countries themselves; only 20% comes from international donors.

 

Dr. Raviglione said there “is no question in my mind that TB is badly underfunded compared to AIDS and malaria.” AIDS gets far more funding than TB despite the facts that the health burdens of the two diseases are comparable, he said, and TB kills more people than malaria.

In 2014, will family planning be able to sustain the euphoria of London and Addis Ababa?

19th Feb 2014

By David J. Olson

2012 was a watershed year for international family planning, with the UK government and the Bill & Melinda Gates Foundation holding the high profile London Summit on Family Planning where new commitments of $2.6 billion were secured, enough to provide contraceptives for 120 million more women and girls in 69 very poor countries by 2020.

In 2013, this effort morphed into a global partnership dubbed Family Planning 2020 (FP2020). The process received a further moral and financial boost in November at the 3rd International Conference on Family Planning in Addis Ababa, where five countries made new commitments (Benin, Democratic Republic of Congo, Guinea, Mauritania and Myanmar) and FP2020 released its first progress report on successes realized since the London Summit. Ethiopia was chosen as the conference site because of its status as an emerging family planning success story in Africa.

Indeed, the U.S. Agency for International Development named these partnerships to advance family planning as one of the 2013 highlights in global health (with “Innovations in Contraceptive Technologies” as another).

But what will 2014 bring for family planning? I believe 2014 is the year that will show if those donors were really serious about their commitments and if we really have a shot at creating 120 million new users.

Despite the fact that the London Summit took place more than 19 months ago, it is still too early to know if donors will keep the commitments they made there. However, preliminary data from an analysis conducted by the Kaiser Family Foundation indicates that donor government disbursements for family planning increased in 2013, according to FP 2020. In most cases, though, we don’t know how much it increased.

Last year, the Kaiser Family Foundation also conducted an analysis of family planning assistance disbursed the prior year by the 24 governments that are members of Organization for Economic Cooperation and Development and Development Assistance Committee, which will serve as a baseline to track donor disbursements annually. We do know, according to FP 2020 and the Kaiser analysis:

  • Increases in spending on family planning by the U.K. and the Netherlands in 2013 have already fulfilled their London Summit commitments.
  • 29 developing countries have made commitments, including the five new commitments made at the Ethiopia conference.
  • One-quarter of FP2020 commitment-making countries have launched detailed, costed national FP plans.
  • One-third of commitment-making countries have increased their national budget allocations for FP services or supplies.
  • Half of commitment-making countries have held national FP conferences to emphasize high-level political support and to accelerate progress on strategies.

At the conference in Ethiopia, I picked up on a few themes that I think will have to be addressed in order for FP 2020 to achieve its ambitious mission:

  • Engaging with faith leaders: The family planning community must collaborate more closely with family planning-friendly faith-based organizations (FBOs) not just in word, but also in deed (including funding). Faith leaders were well represented at the London Summit and the Ethiopia conference but none was given a speaking role or any meaningful responsibility in organizing these events. Faith leaders have sought to participate in the governance structure of FP2020 to little avail. Many faith leaders are ready, willing and able to join this effort but it will not make a difference until the secular family planning community joins hands with them in a real partnership. FBOs can contribute both through their service delivery infrastructures (estimated to constitute 25-50% of total services in some countries) and by educating religious leaders and communities to increase acceptance and demand for family planning. A report published this month shows just how much FBOs are already contributing.
  • Engaging young people: This is something that the family planning community has done well, at least at the Ethiopia conference, where I was struck by the number and engagement of young Africans. That engagement is less evident in FP2020 but it must continue, as current family planning leaders age and youth continues to occupy a large proportion of the FP2020 target countries’ populations. When we engage youth, we have to make sure our language is attuned to their needs. For example, the term “family planning” may be a misnomer, as Laura Hoemeke of IntraHealth suggested in this blog, because young people are not, in most cases, planning families. Hoemeke suggested that “future planning” might be a better term. The Lancet also made this point, in a different way, in this piece.
  • Engaging the private sector: The commercial sector was present and engaged both in London and Addis Ababa but mostly this was in the form of a couple of large pharmaceutical company and one session at each event. Beyond that, they didn’t have much of a presence. The family planning community recognizes the importance of the private sector and I think we’ll be seeing more efforts to engage them. This is important for a number of reasons, not the least of which is that greater private sector engagement will help in making family planning sustainable.
  • Targeting middle-income countries: Chris Purdy, the new president of DKT International, has questioned whether we will meet the goal of reaching 120 million new users by 2020 if we only target the world’s poorest countries, as FP2020 is aiming to do. This is because there are huge pockets of poor people who need family planning in middle-income countries like Indonesia, South Africa and Mexico. Purdy doesn’t believe we can reach 120 million new users without investing in these countries. He laid this out in more detail in his article in the Huffington Post, which was also published on the website of the Ethiopia conference, but it didn’t generate much reaction.

 

Family planning advocates have done an admirable job of putting their issues on the international agenda and mobilizing financial commitments in 2012 and 2013. In 2014, we’ll start to see to what extent those pledges are converted into cold, hard cash.

 

Debate on Post-2015 Agenda Tops Global Health Issues of 2013

20th Dec 2013

By David J. Olson

Undoubtedly, the biggest global health story as we approach the end of 2013 is the debate on the post-2015 agenda; that is, the framework that will replace the Millennium Development Goals (MDGs) which expire in 2015. Arguably the second biggest story is the financing of global development, including health.

The latter will determine how global health fares in the next few months and years. But the former could well determine its fate for the next few decades. And this discussion leads us directly to some of the other key global health issues of late 2013.

Where are we with post-2015?

Last year, UN Secretary General Ban Ki-moon named British Prime Minister David Cameron, Liberian President Ellen Johnson Sirleaf and Indonesian President Susilo Bambang Yudhoyono to co-chair a high-level panel (HLP) to come up with a new vision of development. The HLP met for the first time last September at the UN General Assembly. Since then the HLP has met in Liberia and Indonesia, and there has been a whole series of meetings and consultations by the UN, governments and civil society on all issues related to global development, including one on health in Botswana in 2013. http://www.theguardian.com/global-development/interactive/2013/mar/26/future-of-development-timeline

In May, the HLP released their report http://www.post2015hlp.org/wp-content/uploads/2013/05/UN-Report.pdf on its vision and priorities for post-2015 development, which called for an end to extreme poverty by 2030 and a universal agenda driven by “five big, transformative shifts”: Leave no one behind; put sustainable development at the core; transform economies for jobs and inclusive growth; build peace and effective, open and accountable institutions for all; and forge a new global partnership.

In July, the World Health Organisation (WHO), in its own report on the place of health in the post-2015 agenda, http://apps.who.int/iris/bitstream/10665/85535/1/9789241505963_eng.pdf criticized the HLP report, saying it was “not as transformational, ambitious or coherent as one might have hoped, and that the interconnectedness of today’s global challenges is not well reflected in the HLP’s framework.” It says: “Health needs to be prominently positioned in the post-2015 development framework – this is not yet ensured.”

WHO also said the framing of health is “narrow, focusing on communicable diseases, child and maternal health without adequately addressing the changing global burden of disease.”

On Sept 25, at the opening of the U.N. General Assembly, world leaders agreed “to take bolder action against extreme poverty, hunger and disease,” according to the U.N. News Centre http://www.un.org/ and called for a summit in September 2015 to adopt the next set of anti-poverty goals. Ban presented a report outlining his vision of post-2015 development, calling for a “new and responsive sustainable development framework that meets the needs of both people and the planet.”

Global health financing

Overall, overseas development assistance fell by 4% in real terms in 2012, according to The Guardian http://www.theguardian.com/global-development/2013/apr/03/aid-rich-countries-falls-oecd However, this was not the case with global health funding. “Despite dire predictions in the wake of the economic crisis, donations to health projects in developing countries appear to be holding steady, according to the Institute for Health Metrics and Evaluation at the University of Washington. http://www.healthmetricsandevaluation.org/news-events/news-release/has-golden-age-global-health-funding-come-end And that appeared to be the case in the U.S. as well, with the Obama Administration and the legislative branch finding a rare consensus on global health at least until the current budget impasse. http://www.cgdev.org/blog/global-health-fares-relatively-well-fy14-state-and-foreign-ops-appropriations

That leads to three of the next big global health issues – communicable diseases (AIDS and polio) and non-communicable diseases (NCDs):

The rise of non-communicable diseases (NCDs)

When WHO talks about “the changing global burden of disease,” they are really talking about the rise of NCDs on the global stage. http://www.healthmetricsandevaluation.org/gbd/news-events/news-release/massive-shifts-reshape-health-landscape-worldwid September marked the second anniversary of the U.N. High Level Meeting on NCDs, where the world formally acknowledged the need for urgent action on these under-recognized diseases. Thanks to the 2011 meeting, NCDs are finally getting some respect: In May, the health ministers of 194 WHO member states adopted the Global Action Plan for Prevention and Control of NCDs 2013-2020, http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2813%2961457-9/fulltext the first specific and measurable global targets and a monitoring framework. A coalition of researchers are calling for a “global fund” for cancer, which they say kills more than AIDS, malaria and tuberculosis combined. http://www.businessweek.com/news/2013-09-30/global-cancer-fund-needed-to-fight-surging-cases-in-poor-nations And a recent article in The Guardian http://www.theguardian.com/global-development/2013/aug/05/road-deaths-cancer-diabetes-africa suggested that the NCDs of cancer and diabetes along with road traffic deaths constituted “hidden epidemics” in Africa. In fact, a World Bank report predicted that road deaths will rise by 80% by 2020, making them the biggest killer of children by 2015, outstripping AIDS and malaria.

A resurgence of polio

Early this year, there was optimism that polio was on the verge of eradication with only 223 cases worldwide. However, dreams of eradication have been dashed by an outbreak of polio in Somalia, Kenya, Ethiopia and Pakistan. http://www.washingtonpost.com/opinions/a-setback-on-polio-in-east-africa/ In October, the U.N. announced that they fear a polio epidemic in Syria http://www.nytimes.com/2013/10/26/world/middleeast/syria-polio-epidemic.html and in November, the first cases of wild polio virus since 2009 appeared in Cameroon. http://www.who.int/csr/don/2013_11_21/ But if we can overcome this last challenge, it will be one of the landmark scientific achievements of all time. http://www.washingtonpost.com/opinions/michael-gerson-polio-is-a-killer-on-the-run/

Family planning picks up steam

Family Planning 2020, http://www.familyplanning2020.org/ a global partnership set up to follow through on the promises of the London Family Summit in 2012, says that FP2020 commitments are starting to kick in. According to Valerie DeFillipo, Director of FP2020, donors are starting to release the funds they committed to at the London Summit. However, I wonder why even though FP2020 says that 70+ new commitments to family planning have been made since the London Summit, the total amount raised in new funding remains at $2.6 billion, the same figure that was announced at the end of the summit in July 2012. The International Family Planning Conference that took place in Ethiopia in November http://www.fpconference2013.org/ raised a lot of expectations and saw the launch of the first Family Planning Progress Report. http://www.familyplanning2020.org/progress What happens in 2014 will give a good sense of whether we will be able to reach the 2020 goals on schedule.

Continued progress against AIDS, with a caveat

Since last year, more and more organizations are using the phrase “AIDS-free generation” in the title of their reports and blogs. And they’re doing it not necessarily to describe something in the distant future, but in the next 5-10 years. On World AIDS 2012, UNAIDS announced that 25 countries had reduced new HIV infections for 50% or more. In May this year, UNAIDS reported that, in Africa, the number of new infections has fallen by 32% from 2001 to 2011. http://www.unaids.org/en/resources/presscentre/pressreleaseandstatementarchive/2013/may/ But this genuine hope is accompanied by the harsh reality that this will not happen unless we do a better job of reaching four populations at high risk: people involved in commercial sex, people who inject drugs, men who have sex with men and transgender people.